As APTA continues to advocate for the maintenance of essential health benefits (EHBs) in insurance offered through Affordable Care Act (ACA) marketplaces, the association and other stakeholders are facing another potential challenge to patient access to care: private insurer short-term, temporary health plans that can skirt many ACA requirements around EHBs, preexisting conditions, and continued coverage.
Earlier this month, the Department of Health and Human Services (HHS) adopted a final rule on the short-term plans, allowing the policies to provide 1 year of coverage, renewable for up to 3 years. Previously, the plans could only be used for a maximum of 3 months.
The plans are intended to offer a cheaper insurance alternative than plans available through the ACA (although most individuals who purchase insurance through the ACA marketplaces receive subsidies that lower the out-of-pocket costs). But they are not required to comply with many of the consumer protections included in ACA plans. Instead, the plans are able to deny coverage of a preexisting condition, drop coverage should a customer’s health status change, and refuse coverage for services such as mental health, prescription drugs—and, possibly, physical therapy.
In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a two-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.
Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.
Congress is back in session, and while other issues may grab front-page headlines, the next few months also could prove significant for the physical therapy profession—sometimes thanks to the ripple effects of big-ticket legislation, and at other times when lawmakers turn their attention to more physical therapy-specific bills.
PT in Motion News asked Ken Sprague, APTA’s senior congressional affairs specialist, about the legislative issues that should be on the radar of physical therapists (PTs), physical therapist assistants (PTAs), students, and their supporters. Here’s Sprague’s list of the top 5 issues to track over the coming weeks:
1. Repeal of the Medicare Therapy Cap
Congress is arguably closer than it’s ever been to coming up with partial or full repeal of the Medicare therapy cap. A bill in the US House of Representatives to end the cap has strong bipartisan support, with 177 cosponsors as of late July.
The latest version of the US Senate’s health care legislation may include tweaks intended to please critics of the earlier draft, but the changes aren’t enough to alter APTA’s position that the bill would decrease access to care for millions of Americans.
The revised Better Care Reconciliation Act (BCRA) is the Senate’s second attempt to rollout a bill that would repeal and replace many provisions of the Affordable Care Act (ACA). The original version of the legislation was withdrawn just before the Senate’s July 4th recess, when it became evident that the bill didn’t have enough support to reach the floor for debate.
While Congress and the White House discuss what, if anything, will be offered as a replacement for or adjustment to the Affordable Care Act (ACA), APTA and other organizations are staking out their positions on policies that should remain no matter what. At the top of that list: ensuring access to care through the continuation of rehabilitation services and devices as an “essential health benefit” (EHB) that must be provided to patients.
Recently, APTA joined a group of 46 national clinician, consumer, and membership organizations known as the Coalition to Preserve Rehabilitation (CPR) in a joint letter to Congress expressing opposition to any health care reform effort that would drop rehabilitation as an EHB for Medicaid expansion enrollees and would allow waivers so that states could create their own EHBs for ACA private plans (or eliminate EHBs completely). Both of those provisions, along with a third change that would allow states to waive requirements for community ratings to contain insurance costs—also opposed by CPR—were included in the American Health Care Act (AHCA) that was introduced and then withdrawn in the US House of Representatives.
Last year, spending on health care in the US rose at its fastest rate since the 2008 recession, climbing 5.3% to $3.03 trillion, and representing 17.5% of the country’s gross domestic product. It’s a rise more or less in line with predictions, and one that has a lot to do with expanded health care coverage under the Affordable Care Act (ACA).
In a report published on December 2 in Health Affairs, the Centers for Medicare and Medicaid Services’ Office of Actuaries wrote that “the expansion of insurance coverage, particularly through Medicaid and private health insurance, and rapid growth in retail prescription drug spending” fueled the growth, which outpaced the overall economy.
That overall growth translated into a 4.5% per-capita spending increase, which the report further breaks down into 3 factors: changes in the age and sex mix of the population, medical price inflation, and “residual use and intensity”—basically, the amount of health care usage that remains once the effects of age, population, sex, and inflation are removed. Of those 3 factors, residual use was responsible for nearly half of the 4.5% increase, with medical price inflation not far behind at about 40% of the increase. Demographic changes accounted for about 13% of the growth. Bottom line: more people are using more health care, largely due to expanded coverage made available through the ACA, with some analysts theorizing that the lack of insurance created a “pent-up demand” for certain procedures.
The US Department of Health and Human Services Office of Inspector General (OIG) has issued a proposed rule on civil monetary penalties and exceptions to the anti-kickback statute, and APTA is helping members understand how the changes could affect physical therapists (PTs).
APTA posted a summary of proposed rule (under the “Patient Protection” header) from OIG. Many of the proposals deal with carving out new “safe harbors” for the anti-kickback statute, and refining—and in some cases, loosening—rules around what activities would be considered illegal remuneration. Some of the proposed changes codify existing statutory provisions of the Affordable Care Act (ACA).
Estimating a net decrease of .3% to home health agencies for next year, the Centers for Medicare and Medicaid Services (CMS) has released its proposed rule for the Home Health Prospective Payment System (HH PPS) for 2015. The rule proposes a home health market basket update of 2.2% adjusted for multifactor productivity as mandated by the Affordable Care Act (ACA), and includes a requirement that functional therapy reassessments be conducted every 14 days.
CMS will implement the second year of the ACA-mandated 4-year phase-in for rebasing adjustments to the HH PPS payment rate by decreasing home health payment by 3.5 percent. The proposed national, standardized 60-day episode payment for 2015 is $2,922.76. The proposed per-visit amount for physical therapy in 2015 is $139.73 for home health agencies (HHAs) in compliance with quality reporting requirements.
A March 20 and 21 meeting of the Federal Trade Commission (FTC) examined activities and trends related to cost, quality, access, and care coordination that may affect competition in the US health care industry. APTA representatives attended the event and provided pre workshop comments that pressed for greater patient access to physical therapists (PTs), the elimination of physician self-referral, and expanded health care networks under the Affordable Care Act (ACA), among other issues.
The meeting, “Examining Healthcare Competition” was attended by APTA staff and included panel discussions and presentations on the professional regulation of health care providers, measuring the quality of health care, and the interplay between quality and price transparency, among other topics.
Though a House-approved bill to end the flawed sustainable growth rate (SGR) is almost certain to be a nonstarter in the Senate, a Senate bill that would end both the SGR and the therapy cap is now gaining momentum and is the focus of renewed grassroots advocacy efforts from APTA and other organizations. Physical therapists (PTs), physical therapist assistants (PTAs), physical therapy students, and supporters are being urged to contact legislators to push for passage.
On March 14, the House voted 238-181 to approve a bill that would pay for the cost of SGR repeal by delaying enforcement of the individual mandate in the Affordable Care Act (ACA). The political implications of the bill are widely viewed as unacceptable to the Democratic-controlled Senate, which so far has refused to take up the bill. The White House has threatened a veto of the bill if it should pass both houses.