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.
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.
Technology continues to advance at an exponential rate, but what does that mean for the profession? More important, what does it mean for patients in the here-and-now?
The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, includes multiple sessions that go beyond the wow factor of technology and gets to practical applications in the clinic. Check out these suggestions, and find other relevant programming by searching the CSM programming page.
Why We Love AND Hate Our Robots: Implications for Everyday Clinical Practice
When it comes to the utilization and efficacy of robotic technology in rehabilitation of individuals with neurological diagnoses such as stroke and spinal cord injury, the research can be both encouraging and discouraging. What’s behind the discrepancy in outcomes? Learn about the good and the not-so-good in robotic technology, implications for clinical practice, and when other evidence-based therapies are worth considering. Friday, January 25, 3:00 pm–5:00 pm.
APTA has joined with more than 150 other health care organizations to let the US Centers for Medicare and Medicaid Services (CMS) know that while its “Patients Over Paperwork” efforts are appreciated, one CMS attempt to reduce administrative burdens is likely to result in reduced access to care for some of the sickest Medicare beneficiaries.
The concerns center around a provision related to evaluation and management (E/M) visits included in the 2019 physician fee schedule rule proposed by CMS over the summer. The change, ostensibly intended to reduce paperwork, would collapse E/M payment rates currently based on a 5-level complexity system for new and established patients into what would amount to a 2-level system—combining levels 1-3 and levels 2-5. CMS acknowledges that the change would result in higher payments for E/M visits at the 1-3 levels while levels 4 and 5 will see reductions based on the 2019 proposed relative value units. However, CMS argues, the reduced paperwork burden would offset the payment drop.
In a letter sent to CMS last month, APTA and other cosigners praise CMS for its initiative to reduce provider paperwork, but question the wisdom of the E/M plan, arguing that the change would unfairly impact providers who see sicker patients, “ultimately jeopardizing patients’ access to care.”
The final 2019 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are substantially similar to what the Centers for Medicare and Medicaid (CMS) proposed in the spring, but that’s not to say physical therapists (PTs) should assume it’s a “same rule, different year” situation.
In fact, the situation is far from a “same as usual” scenario—at least for PTs in SNF settings, who will be facing a dramatic change in how payment is determined.
The new rules, set to go into effect in October of this year, include increases in payment of 2.4% for SNFS and 0.9% for IRFs, but the heart of the changes have less to do with payment increases and more to do with how payment will be determined and what needs to be reported. For PTs in IRFs, the reporting process could become a bit less burdensome, while PTs in SNFS will need to get up to speed with an entirely new payment system that does away with the Resource Utilization Groups Version IV (RUG-IV) process.
In its ongoing efforts to decrease regulatory burdens, the US Centers for Medicare and Medicaid Services (CMS) has turned its attention to a law that, with the exception of physical therapy and a few other treatments and procedures, bars physicians from referring patients to services in which the physician has a financial interest. The CMS call for feedback—an effort largely focused on how the law might be loosened up—comes at a time when APTA and other organizations are voicing support for a bill that would do nearly the opposite by eliminating the exemptions allowing for self-referral for physical therapy and other services.
The CMS Request for Information (RFI) is part of an initiative dubbed the “Regulatory Sprint to Coordinated Care.” According to CMS, the focus of the initiative is on “identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care.”
With nearly a third of the total Medicare population enrolled in a Medicare Advantage (MA) plan and growth expected to continue, it’s time for the public-private hybrid system to evolve and move away from excessive use of prior authorization—that’s the message being delivered to the Centers for Medicare and Medicaid Services (CMS) from a coalition of health care and consumer organizations including APTA.
In an April 10 letter to CMS Administrator Seema Verma, the Coalition to Preserve Rehabilitation (CPR) writes that MA’s uses of prior authorization “may be sources of increasing barriers to accessing needed care, particularly inpatient and outpatient rehabilitation services and devices, for beneficiaries nationwide.” The coalition argues that in many cases, prior authorization “often serves as an unnecessary delay for beneficiaries seeking medically necessary care, and often results in no cost savings to the plan.”
A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.
The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers’ negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.
APTA’s Physical Therapy Outcomes Registry (Registry) has been approved again by the US Centers for Medicare and Medicaid Services (CMS) as a qualified clinical data registry (QCDR). The designation for 2018 means that physical therapists (PTs) who participate in the Merit-based Incentive Payment System (MIPS) program can submit their data directly from the Registry, but the CMS approval is also an acknowledgment that APTA offers a robust, reliable system for tracking and benchmarking patient outcomes.
Although voluntary for now, PT participation in MIPS could be mandatory as early as 2019, making it important to become familiar with the system (APTA encourages eligible PTs to voluntarily participate in MIPS now).The Registry’s QCDR status will be particularly helpful for practices whose electronic health records (EHRs) do not have the capability to report directly to MIPS.
According to Heather Smith, PT, MPH, APTA’s director of quality, the value of the Registry goes well beyond MIPS data submission.
Efforts by the US Centers for Medicare and Medicaid Services (CMS) to make Medicare Advantage (MA) plans more accessible to more vulnerable beneficiaries are laudable, and provisions that would steer patients away from overuse of drugs are understandable, but CMS needs to be mindful of the unintended consequences of these and other changes, says APTA in its comments on proposed MA rules changes for 2019.
At the center of APTA’s comments are proposed changes to so-called “uniformity requirements,” out-of-pocket limits, and frequently abused drugs. Essentially CMS would like to make it easier for more vulnerable individuals to participate in MA plans by reducing cost-sharing requirements, and harder for providers and patients to overutilize certain drugs, including opioids. Both efforts are worth pursuing, APTA says in its comments to CMS.