Looking back over 2018, it’s hard to overstate the magnitude of Medicare-related changes experienced by physical therapists (PTs), physical therapist assistants (PTAs), and their patients. It was a year that included the end of the hard cap on therapy services under Medicare and the announcement of the inclusion of qualifying PTs in its Quality Payment Program starting in 2019—a dramatic shift toward value-based payment. And did we mention the launch of new requirements for skilled nursing facilities (SNFs) beginning later in 2019?
While payment news is almost always of interest to PT in Motion News readers, keeping up with the US Centers for Medicare and Medicaid Services (CMS) was apparently top-of-mind in 2018, as Medicare-related stories dominated this year’s list of most-read News items.
Given some of the major shifts in the Medicare payment landscape over the past few years, gaining an understanding of even the big-picture workings of the system can be a tall order. The Medicare Payment Advisory Commission (MedPAC) offers an updated resource that can help.
Now available for free download: MedPAC’s latest version of “Payment Basics,” a series of informational sheets that describe the need-to-know elements of 20 different Medicare payment systems. Areas covered include outpatient therapy, skilled nursing facilities, home health services, hospital acute inpatient services, and more. The newest version of the resource updates the 2015 edition.
Most information sheets provide background on how the system is organized and flowcharts for a visual representation of how that particular payment system works.
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.”
For years, confusion has surrounded the conditions under which older adults can receive physical, occupational and speech therapy covered by Medicare.
Services have been terminated for some seniors, such as those with severe cases of multiple sclerosis or Parkinson’s disease, because therapists said they weren’t making sufficient progress. Others, including individuals recovering from strokes or traumatic brain injuries, have been told that they reached an annual limit on services and didn’t qualify for further care.
Neither explanation stands up to scrutiny. Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy. Nor does it limit the amount of medically necessary therapy, for the most part.
Beers, a retired railroad engineer who lives outside Sacramento, Calif., has a form of Parkinson’s disease. The treatments slow its destructive progress and “he will need it for the rest of his life,” Morse said.
But under a recent change in federal law, people who qualify for Medicare’s therapy services will no longer lose them because they used too much.
“It is a great idea,” said Beers. “It will help me get back to walking.”
After 20 years of opposition from APTA and 17 years of 11th-hour congressional patches to an inherently flawed policy, the Medicare therapy cap may be on its way out for good.
But nothing’s certain yet, and there are many details still to be worked out.
On October 26, APTA representatives attended a meeting on Capitol Hill during which lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. The road from proposal to actual repeal can be long, and success isn’t guaranteed, but if the proposal survives, it would represent a major victory for patients and the physical therapy profession.
In its push toward outcomes-based models, the US Centers for Medicare and Medicaid Services (CMS) needs to take a closer look at wound care, say authors of a new study that estimates nearly 15% of all Medicare beneficiaries experience chronic nonhealing wounds at an annual cost of nearly $32 billion. And the researchers believe those numbers are on the conservative side.
The study, recently published in Value in Health, analyzed data from Medicare’s 5% Limited Data Set during 2014 for details on claims in which wounds were the primary or secondary diagnosis. Researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, chronic ulcer, pressure ulcer, skin disorders, skin infection, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infection. Here’s what they found:
In 2014, approximately 14.5% of Medicare beneficiaries were diagnosed with at least 1 type of wound or wound infection—that’s about 8.2 million patients.
When it comes to physical therapy for treatment of low back pain (LBP), Medicare is getting a bargain, according to authors of a new study. Researchers say that not only is physical therapy cheaper than injections or surgery in the short-term, it’s an approach that is likely to save on treatment costs for at least a year after initial diagnosis, with average savings of 18% over treatments that begin with injections and 50% over treatments that begin with surgery.
The study, commissioned by the Alliance for Physical Therapy Quality and Innovation (APTQI), focused on Medicare A and B claims data from 472,000 beneficiaries who received a diagnosis of LBP and began treatment between February and October of 2014. Researchers from the Moran Company tracked 3 treatment paths—physical therapy, injections, and surgery—and compared total costs of initial treatment as well as total costs for 12 months after diagnosis. The study also included an analysis of cost differences associated with how soon physical therapy was initiated after diagnosis, the physical therapist interventions used, and relationships between the use of physical therapy and the referring health care provider.
That’s the major takeaway from the proposed Medicare 2018 physician fee schedule released by the US Centers for Medicare and Medicaid Services (CMS). It’s a plan that settles questions about potentially “misvalued” current procedural terminology (CPT) codes by generally accepting work relative value units (RVUs) that had been proposed by an American Medical Association (AMA) advisory committee that worked closely with APTA.
Under the proposed fee schedule, 13 of 19 CPT codes frequently used by physical therapists (PTs) will retain their 2017 RVUs, with the remaining 6 seeing slight increases. Additionally, RVUs for 2 codes associated with the management and training of patients with orthotics or prosthetics were increased, and a new code was added (977X1, intended for use on a “subsequent encounter” or different date of service from the initial encounter).
Medicare could become a much more welcoming place for telehealth services if Congress passes 2 pieces of legislation recently introduced in the US House of Representatives. The 2 separate bills would have the combined effect of expanding where and how telehealth services can take place, which patients are permitted to receive the services, and the list of health care professional who can provide the services—a list that includes physical therapists (PTs).
The bills—1 called the Medicare Telehealth Parity Act, and a second known as the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act—propose changes to the way Medicare handles a number of issues, from remote monitoring of patients with chronic conditions, to a reworked definition of reimbursable telehealth codes. In addition, the parity act expands the list of providers who can provide telehealth services to PTs, respiratory therapists, occupational therapists (OTs), speech language pathologists, and audiologists, while the CONNECT act would allow PTs in some bundled payment arrangements, accountable care organizations (ACOs), and Medicare Advantage plans to participate in telehealth arrangements.