Bradley Grohovsky, PT, DPT
As the United States health care climate continues to evolve with the implementation of the Affordable Care Act under President Obama, it is vital that our profession continues to evolve if we are going to continue to Move Forward and live our newly adopted Vision: “Transforming society by optimizing movement to improve the human experience”. This evolution requires: A) challenging ourselves as autonomous practitioners B) holding our colleagues responsible for consistent growth and innovation so we are able to better meet the needs of our patient’s and fulfill our increasing role as primary care practitioners C) advocating for our patient’s by continually challenging and representing the role of our profession.
On July 22 and 23, over 85 members of the Private Practice Section (PPS) of the APTA attended the section’s first ever “fly-in” to Washington, DC - comprised of small business owners and physical therapist practitioners from 34 states. As a PPS government affairs committee-member, I had the privilege of being involved in both planning and participating in this inaugural event. The main goal of the fly-in was to represent our place as private PT’s in the medical model and influence our standing as primary practitioners in health care and payment reform - emphasizing a value vs. (current) volume driven model. To achieve this change there are several key issues that we addressed and continue to pursue following the outreach to our Representatives. The following is a brief summary of the issues that are most pressing for our profession and practice: Sustainable Growth Rate (MPPR), Therapy Cap, Referral for Profit, Medicare Opt Out and Locum Tenens.
Sustainable Growth Rate
The currently flawed Sustainable Growth Rate and Therapy Cap that influence both physician and non-physician payment were created in 1999 with the task of reducing Medicare payments. This rate is based on a calculation that health care costs should grow at a rate similar to our GDP. However, following the recessions of the early 2000’s and 2008 our economy has slowed at a much greater rate, while health care costs have continued to rise. This imbalance creates the current 24% cuts that Congress “hustles” to prevent every year. Every lawmaker on the Hill agrees that this is an extremely flawed formula, however it costs billions of dollars to repeal and reform Medicare payment. Recently, however, the opportunity for reform and repeal has gained significant traction in both The Energy and Commerce Committee and the Ways and Means Committee in the House. Further, the Senate Finance Committees are working on proposals to revamp the fee-for-service component of the payment system so that payment is based on performance measures rather than just on services delivered. The APTA has been a leading voice on the Hill, working with these committees by providing recommendations and responses on an alternative payment model.
Due to the direct connection that the Therapy Cap and SGR have, congressional action to reform the SGR formula should include provisions that permanently reform the outpatient therapy cap - the PPS currently supports the Medicare Access to Rehabilitation Services Act (HR 713/S 367). This Act would permanently repeal the $1,900 therapy cap imposed on PT, OT, SLP services. In addition, reform of the SGR would likely include changes and possibly repeal the Therapy Cap.
PPS members went to the Hill with specific points and challenges for Representatives:
1. Repeal the SGR that determines annual Medicare therapist and physician payments.
2. Create 5-year period of payment stability by specifying payment rates.
3. Use the transition period to determine effective health delivery alternatives (APTA is already working on a severity (of illness/diagnosis)-intensity (of treatment) payment model.
4. Link therapy cap reform to SGR as has been done since both policies originally enacted.
The PPS supports H.R. 2810 (Medicare Patient Access and Quality Improvement Act of 2013), a draft of which passed the Health Subcommittee by voice vote recently, and was introduced by Rep. Michael Burgess (R-TX), Rep. Frank Pallone(D-NJ), Rep. Fred Upton (R-MI), Rep. Henry Waxman (D-CA), Rep Joe Pitts (R-PA), and Rep. John Dingell (D-MI).
In-Office Ancillary Services Exception
The IOASE was created as a response to the physician self-referral prohibition (commonly referred to as the Stark Law) and the original intent was primarily for efficient care, allowing surgeons to directly oversee his/her patient’s care. This exception resulted in what we know as “POPTS”. The orthopedists do not want to lose control of this exception and have placed it as their #1 priority on the Hill. Unfortunately, most of us have probably heard several patient testimonials on the inefficiency and lack of quality care that some of the offices covered under this exception provide. The Office of Management and Budget recently concluded that closing the loophole for these services would provide a savings of $6.1 billion over a 10-year window, proving that self-referral leads to overutilization of Medicare services. Just think of the savings if many of these patients had been working with a PT prior to undergoing surgery!
The PPS is urging that Congress remove PT services from the IOASE.
Update: Legislation was introduced on August 1st by Representative Jackie Speier (D-14th/CA) that eliminates physical therapy from the IOASE.
Physical Therapists Opting Out of Medicare
As we all know, PT’s are not currently among the list of providers who can opt-out of accepting Medicare. There is congressional concern that if physicians refuse to bill Medicare for services furnished to beneficiaries, there could be a potential access problem for Medicare beneficiaries. Currently, private contracting is only authorized for physicians, osteopaths, podiatrists, dentists
and optometrists and selected non-physician providers. In opt-out situations, beneficiaries are liable for payment for the costs of their own care. If a provider chooses to opt out of billing Medicare for services provided to program beneficiaries, he/she can not receive payment linked to Medicare HMO capitation payments for 2 years after the effective date of opt-out in the affidavit. This would allow physical therapists who do not accept Medicare (or are cash-based) to still treat Medicare beneficiaries while maintaining the flexibility to rejoin the program in the future!
The PPS is urging Congress to add PT’s to the list of providers currently allowed to opt-out of the Medicare program provided all other requirements for opting-out are met.
The locum tenens arrangement is a longstanding and widespread practice for physicians to retain a substitute physician in their professional practices when they are absent due to illness, pregnancy, vacation or continuing ed. Currently PT’s may not utilize a “substitute” and receive payment if they are not employed in the same practice.
The PPS is urging Congress to add PT’s to the list of providers allowed to utilize locum tenens arrangement under Medicare.
Update: Congressman Ben Lujan (D-NM) announced at the fly-in that he will champion legislation to include PT’s in locum tenens and is currently searching for a Republican co-sponsor.
It is my personal opinion that physical therapists prophylactic mentality has been decades ahead of the current recommendations, with a treatment approach that exemplifies quality patient care and not quantity of treatment units or number of patients that we see in our practice. Based on the current recommendations, there is opportunity for our profession to Move Forward and reimburse based on patient outcomes - and who optimizes function and quality of life better than physical therapists?!
What you can do...
Join the Private Practice Section who represents your practice and business interests:
Contact your representative - Log into the Legislative Action Center
And..Attend a town hall meeting during Congressional recess August 3rd - September 7th. Log into the Legislative Action Center and check your local events under the “Grassroots Resources” tab.
Bradley Grohovsky serves on the APTA Private Practice Section Government Affairs Committee and is currently a Resident studying with the Institute of Physical Art at Encompass Physical Therapy in Annapolis, MD specializing in Functional Manual Therapy. Brad is a 2011 graduate of Simmons College DPT program and is also a former member of the APTA Student Assembly Board of Directors.