Medicare self-referral loopholes—the exception that allows physicians to refer patients for physical therapy and other services to a business that has a financial relationship with the referring provider—is once again in the legislative spotlight on Capitol Hill.
On April 6, the Promoting Integrity in Medicare Act (PIMA) was reintroduced in the US House of Representatives (HR 2066), in hopes of eliminating the exception to the federal law originally intended to prohibit self-referral. That law, known as the Stark law, does prohibit most self-referral practices, but it also contains language that allows physicians to self-refer for “patient convenience” or same-day treatments—known as in-office ancillary services. Unfortunately those exceptions also include services that are rarely provided on the same day—physical therapy, anatomic pathology, advanced imaging, and radiation oncology.
Topics may have ranged from the opioid abuse epidemic, to APTA’s physical therapy outcomes registry, to the role of physical therapy in population health, but throughout APTA’s recently held Insurers Forum and State Policy and Payment Forum, it wasn’t hard to identify the strong common thread woven through nearly every session:
Things are getting real.
Over and over, speakers reminded attendees that what used to be conjecture about the move toward value-based care—and particularly its ramifications for payment—is now happening, and that physical therapists (PTs), physical therapist assistants (PTAs), payers, managers, and state policy advocates need to pay attention.
With half of all workplace assaults involving health care workers already, and the number of violent crime episodes in hospitals on the rise, it’s time for health care facilities to address workplace violence “aggressively and comprehensively,” say authors of an editorial recently published in JAMA.
The “Viewpoint,” written by 2 employees of the Joint Commission and a representative from a Veterans Health Administration workplace violence prevention program, cites data from the Joint Commission, Occupational Safety and Health Administration (OSHA), and Bureau of Labor Statistics (BLS) to outline what they assert is a growing problem.
The squeeze continues: according to a new report, the cost of health care for a typical family of 4 covered by typical employer-sponsored preferred provider organization (PPO) has more than doubled over the past 10 years, with employees experiencing a faster rate of increase than employers, thanks to higher out-of-pocket demands and rising employee payroll deductions.
The 2015 Milliman Medical Index report pegs the average cost of health care for a family of 4 at $24,671—that’s a 6.3% increase, and a noticeable uptick from 2014’s 5.4% increase, one of the lowest recorded by Milliman since it began its studies in 2001.
Milliman points to a rise in prescription drug prices as the biggest reason for the increase, a category that grew by 13.6% from 2014 to 2015. According to the report, the increase was fueled by wider use of specialty drugs—drugs that cost more than $600 per prescription—and more demand for compounded drugs. Overall, prescription drugs accounted for 16% of a family’s health care costs.
Data breaches of protected health information (PHI) aren’t just a challenge for health care providers: according to a new report, it’s a problem that has been experienced in 90% of all industries, from agriculture to entertainment. And those compromises could be changing patient behavior.
In its recently released PHI Data Breach Report (.pdf), researchers for Verizon analyzed reported PHI data breach incidents in 25 countries from 1994 to 2014. Unlike other analyses that searched for records of breaches filed under “health care” in the North American Industry Classification System, the Verizon report expanded its review to include not only the health care industry, but any breach in any industry in which the data type lost was listed as “medical records,” or the data subject (victim) of the breach was listed as “patient.”
The widened search yielded 1,972 breaches that affected 392 million records, most occurring between 2004 and 2014. The health care industry was the leader in terms of number of breaches, but nearly every other industry experienced breaches that involved PHIs.
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.
Increasingly, medical schools are requiring that students add one more skill to their bedside manner: an ability to explain and discuss the costs of a patient’s care options.
A recent story from National Public Radio reports on an American Association of medical Colleges (AAMC) survey that showed 129 of 140 of US medical schools now require students to take a course on the cost of health care, with “a vast majority” of programs also integrating discussions of cost and value throughout coursework.
According to NPR, the change is a “departure from the past,” when doctors were expected to provide effective care, “leaving cost considerations aside.”
APTA is pleased to announce the next phase in its effort to improve direct access: you.
Beginning the week of March 30, APTA will conduct a survey of its physical therapist (PT) members to find out how direct access is being used in their practices, and what obstacles still exist. Your participation is key.
Surveys will be sent via email over the course of the week, so keep an eye out (and check those spam filters). And be sure that your member profile is set to receive surveys.
Physical therapists (PTs) in Washington, Oregon, Idaho, and Utah are in for some good news: Regence insurance company has announced that it is abandoning its tiered system for utilization management (UM) that divided PTs and chiropractors into 3 groups with different allowances for preapproved visits. The system will be suspended on July 1.
Instead of the tiered system, all providers will receive an initial authorization for 6 visits, with additional visits approved when providers demonstrate medical necessity. According to Regence, the change is based on Regence data supporting 6 as the number of visits that covers most episodes of care.
Regence plans to send letters to providers informing them about the change at the end of March.
As the Department of Health and Human Services (HHS) continues its evolution away from fee-for-service payments and toward “value based” models, a new opportunity to shape that evolution is being offered to providers, payers, the public, and other stakeholders.
It’s called the Health Care Payment Learning and Action Network (Network), and APTA will be there from the start.
On March 25, HHS debuted the Network, which it describes as “a forum for public-private partnerships to help the US health care payment system (both private and public) meet or exceed … Medicare goals for value-based payments and alternative payment models.” Those goals call for 90% of Medicare payments to be tied to quality or value within 3 years.