Priorities for 2017

It has been a busy 2017 already for the outpatient rehabilitation world and in turn for the Alliance.  We continue to focus on our mission of ensuring patient access to value driven physical therapy care.  To accomplish our mission, we have been working on several different areas.  First, we are continuing to follow the payment and coding reform initiatives that relate to our profession.  Attending the AMA CPT Editorial meetings provides us keen insight into how the code change process occurs.  We are also in contact with the APTA, AOTA, NATA and other professional organizations related to outpatient practice to stay abreast of their perspectives in the relevant topics.  Second, in late 2016, the Alliance began an engagement with the Moran Group, a Washington-based health care research and consulting firm focused on the public and private sectors in health care.  The project is based around the value of physical therapy and uses Medicare data to attempt to demonstrate that value.  The final results of the work are forthcoming and we will be sharing the Moran Groups white paper in the future. One other area we have spent considerable time is on outcomes.   Several of our Alliance board members have spent time working on a task force, in collaboration with the APTA, on defining, reviewing and developing a framework for outcomes data utilization in outpatient physical therapy.

There are many other areas we have been working on and we look forward to sharing more with you in the future.  Our profession does have several important items that are pressing on us at this point.  I have highlighted them below:

  1. Misvalued Codes – the misvalued codes process in underway, as planned by CMS. This process has been in the works for several years and CMS recently set a deadline to complete the misvalued analysis.  What does this mean?  Twenty-one codes, virtually all of the main codes we use, are being reviewed as potentially misvalued.  By misvalued, that usually means overvalued.  The Alliance has been in close contact with the APTA about the process, but the APTA is unable to share all of the information on the process due to the confidentiality around the AMA RUC.  The proposed rule by CMS is due to come out in early July 2017.  Once the proposed rule is published, there is a comment period where we are able to share feedback with CMS.  As we did for the evaluation code changes, we will make comments on the new rule. CMS posts their final rule in the Fall and implementation of the new values may occur as early as January of 2018.  The Alliance had a good meeting with key CMS leadership in the fall of last year and we are working to set up a follow up meeting.
  2. Orthotics and Prosthetics Proposed Rule – CMS has a proposed rule out that would severely limit the ability of physical therapists and occupational therapists to bill and be reimbursed for custom orthotics and prosthetics. The comment period closed on March 13, 2017 and the Alliance submitted a comment letter to CMS.  I have also attached the letter to CMS from the Alliance.

 

Thank you for taking the time to read our update and please let us know if you have any questions or concerns impacting our profession.  The Alliance is there to advocate for our profession.

Troy Bage PT, DPT

Executive Director

APTQI

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A word from Troy Bage, APTQI’s executive director

I am excited to begin a monthly blog post for the Alliance for Physical Therapy Quality and Innovation (APTQI, or the Alliance).  As some of you know, our Alliance came together around the topic of payment reform back in 2013.  We wanted to ensure that our profession was best positioned for the changing healthcare environment we all live in.  Our group followed the proposed payment reform plans and advocated for transparency of the process and a focus on rewarding quality clinical outcomes.

Since the beginning, the Alliance has advocated for payment reform measures that are rooted in evidence-based practice and are supported by outcomes data that proves the incredible value we give our patients.  The biggest challenge we face in healthcare reform is how undervalued PT is to the rest of the medical field.  The APTA and AOTA are currently working on the valuation of 10 of our primary codes that CMS has deemed “misvalued.”  By misvalued, they mean over-valued.  It is another potential hit to a profession that has taken too many over the last decade.  If you add up MPPR, PQRS and FLR, we have significantly increased our cost to provide care and have taken a 12-15% payment reduction in the process.  The problem is how CMS and payers are valuing physical therapy.

What if our profession was able to PROVE that $1.00 spent on physical therapy would save $1.25 in the total healthcare spend?  We could change the dialogue that has happened over the last several years about the increasing amount spent on physical therapy.  What dialogue is that?  One of the reasons we have been a target for payment cuts is we have increased from 1.5% of the total Medicare spend to almost 2.5%.  Physical therapy is still a very small amount of the spend, if you ask me, but the percentage increase is concerning to some.

Our future value is to show that physical therapy should be the provider of choice for musculoskeletal pain and dysfunction.  We should be the “first in” provider that is utilized prior to surgery, imaging and other more invasive and expensive procedures and interventions.  Additionally, physical therapy has been noted as a preferred approach for treating chronic pain disorders vs. the use of opioids.  The Centers for Disease Control stated in its Guidelines for Prescribing Opioids for Chronic Pain in the United States – 2016, “The contextual evidence review found that many non-pharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as CBT (cognitive behavioral therapy), and certain interventional procedures can ameliorate chronic pain.  The guidelines state, “There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months. Previous guidelines have strongly recommended aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip. Exercise therapy also can help reduce pain and improve function in low back pain and can improve global well-being and physical function in fibromyalgia.”

The Alliance is currently developing a framework to provide clear data to demonstrate the value of physical therapy at the early stages of care to decrease the total cost of care.  We are excited to be working collaboratively with more than a dozen different providers and some of the most respected names in our industry.  John Childs, a member of the Alliance’s workgroup on innovative models states, “We know from several studies across numerous claims databases that a patient seeing a physical therapist early in the course of care has positive implications on outcomes and costs downstream, including lower utilization of drugs, advanced imaging, and surgery. In fact, the total cost of care for back pain is 50% lower when physical therapy is utilized early.”  Providing additional data across the entire healthcare spend will be a key to advancing the early physical therapy intervention model.  The current BCPI or CJR model for total hip and knee replacements are examples of how CMS is already looking towards total cost per episode vs. per provider.

The Alliance currently represents over 5,400 physical therapy clinics and nearly 20,000 therapists nationwide.  We represent therapists in all 50 states and have a variety of practice settings including traditional outpatient, home health, sub acute rehab facilities, inpatient rehab hospitals and acute care hospitals.  Our group attends all of the national APTA conferences, the AMA CPT Editorial Panel meetings, meets with CMS and congressional leadership to stay on the forefront of payment reform and policy in our profession.   We have strong relationships with the APTA, AOTA and NATA in addition to other key professional organizations.  For more information about the Alliance or to join our cause, please visit APTQI.com.

 

The Physical Therapy Business Alliance joins APTQI!

alliance for physical therapy quality and innovation news

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PRESS RELEASE, NOVEMBER 9, 2015:

With a vision towards providing a focused, agile, and unencumbered response to legislative and payment challenges that improve business conditions for independent physical therapy practices, the Physical Therapy Business Alliance (PTBA) announces that we have formally joined the Alliance for Physical Therapy Quality and Innovation (The Alliance).

As an organization, the Physical Therapy Business Alliance currently represents over 175 private practice physical therapy businesses in 37 States that employ over 14,000 people and a growing professional influence.

The President of the Physical Therapy Business Alliance, Dr. Jeff Hathaway, DPT notes, “With our core value of creative collaboration and seeking out opportunities to partner with other organizations around issues or agendas that are mutually beneficial, joining forces with the Alliance for Physical Therapy Quality and Innovation is a natural step giving our member practices the opportunity to contribute and have a voice.”

Additionally, the synergies created with The Alliance will allow the PTBA to continue toward our member deliverables of:

 Entrepreneurial Solutions:
o Versatile problem solving

 Pro‐active Engagement:
o Anticipate challenges and take action

 Leverage Knowledge:
o Gather and disseminate proven results, targeted resources, and shared experiences

 Passionate Focus:
o We mass energy, commitment, and responsiveness to our stakeholders

Dr. Hathaway further states, “This Alliance that has been forged between the two groups will focus initially on the Alternative Payment System, or what has morphed into the Physical Therapy Classification and Payment System (or PTCPS). We hope that the work of The Alliance will allow Physical Therapists to deliver the necessary care without additional layers of regulation while receiving payment that is commensurate with the education and value that the Physical Therapist brings to the health care arena.” 

Alliance Update – July 16, 2015

APTQI Alliance Update

Well these past few weeks have seen the most public discussion to date with respect to the APTA’s proposed coding changes for the 97000 series codes that govern the billing of our services. Our Alliance’s announcement that we would not continue to financially support our trade group while they were actively working on a plan that we believed (and still believe) will be detrimental and damaging to our member companies, as well as to the entire industry, has brought about a rising tide of awareness and discussion on this critically important topic.

Now is the time when the APTA must step forward and release the FULL and unabridged version of the Gage study which was done to measure the reliability and validity of this proposed coding change. As we mentioned in our earlier correspondence, we received a copy of this report (with all of the data) some 7 months ago under a signed letter of confidentiality. Isn’t it time that the APTA and its leadership trust the members they have been commissioned to serve and transparently step forward with a full copy of that report? Additionally the APTA and its CEO, Michael Bowers have cited “confidentiality provisions” around the AMA process. Our Alliance is interested to know if Mr. Bowers or anyone at the APTA has requested that the AMA relieve them from any confidentiality provision and allow all of the proposed code set information to be released immediately. Additionally, why is there still no full release of the Barbara Gage study 7 months after we received a copy?

It is time to get everyone on the same page with respect to this coding proposal allowing all members to have full access to all of the available information. While we might not all fully agree, then and only then will everyone have the information necessary to make an INFORMED decision with respect to what it might mean for them and their business. It is well beyond time for the APTA to be FULLY transparent about ALL ASPECTS of the proposal and the study results which our member companies, through individual memberships and other events, have helped to fund. It is time to work on a payment reform solution that isn’t just a highly subjective, fee-for-service bundle which will not advance the triple aim goals of healthcare reform, but will create tremendous havoc in the process. It is beyond time to openly and fully discuss all of these issues in the light of day for the entire profession rather than rely on the crumbs, bits and pieces approach we have gotten so far. I think our Alliance and all of its large and small company members as well as our profession deserves better.

To those who have worked to try to build a bridge (even though we haven’t yet fully succeeded), Justin Moore in particular, I am hopeful that he (and we) can convince whoever holds the ultimate decision making power at the APTA that it is time to truly listen to its constituents. When our Alliance met months ago with the APTA board to formally share our concerns with them, we sent a letter (read letter) in advance of that meeting outlining our many concerns. Unfortunately, we were told at the meeting that while they agreed with all of the points in our letter that too much time had been invested in THIS proposal to turn back. Is that what we should really want and expect from our trade group? Shouldn’t we want the RIGHT solution?   We believe thoughtful, well-structured payment reform is necessary. We do not however support what is being proposed by the APTA. It is our sincere hope that at some point we can work together to develop an alternative proposal that puts physical therapy in a position for long-term success as a result of our long-standing contributions. Our profession is certainly part of the solution in reducing unnecessary and wasteful healthcare and we should fight for the RIGHT solution and not accept one that will hurt our practices and our patients. Thank you for standing with us as we work on this important and challenging opportunity. As always, we will do our best to keep you apprised as this issue continues to unfold.

Respectfully,

APTQI members and Associates

Actions taken by the APTA

The APTA 2013 position statement on payment reform can be found on its website.

The APTA has chosen to propose coding system changes (Alternate Payment System-APS) through the AMA CPT Editorial Panel/RUC process.

The APTA’s effort at driving payment reform is a fear based decision and strategy that wrongly assumes consolidating misvalued codes into an alternative fee for service system will somehow make coding valuation a non-issue for CMS and commercial payors.

Over the last year or two, we have expressed significant concerns about this proposal (see Resources) including:

o  Lack of value/quality components

o  Lack of any published reliability and validity in the piloting

o  Lack of member involvement

o  Lack of transparency

o  Despite the significant changes in codes/code definition to capture clinical judgment, severity and intensity, there is no clear connection to value or quality.

o  Associated payment methodologies for the APS proposal have received little or no attention. Reimbursement is a critical issue for any practice and must be part of the discussion now, not after adoption. The AMA RUC process does not prohibit interaction with APTQI beyond surveying.

As a result of APTQI and other trade group insistence, the APTA/AMA CPT workgroup agreed to conduct a pilot and then failed to be transparent in sharing those results with its own members! The latest information on the website dates back to 2013.

The proposed system of new CPT codes will still be “Fee For Service” with all of the existing burden that exists today and lacking any clear plan to address regulatory concerns (MPPR, etc.).

It has been argued by APTA that the current CPT therapy coding system was never tested for statistical reliability and validity and that is not important and slowing down the process.

Despite numerous attempts to collaborate with the APTA, including offering resources (financial and otherwise) in an effort to be both solution and action oriented, the APTA’s action has been to continue pushing forward the plan at the AMA CPT Editorial Panel/RUC level.

In various communications over two years, both informal and formal, our concerns have been communicated to the APTA by the APTQI including a presentation by APTQI members to the APTA Board in April 2015.

The APTA has acknowledged our concerns yet continues to move forward with the current flawed payment model at AMA. Their primary message is centered around on convincing us as to why the APS proposal “is the only way” to accomplish physical therapy coding and payment reform.

We do not support the current alternative fee for service payment system and we think others would agree if given all the facts. We encourage you to inquire about the proposed APS model working its way through the AMA committee process and gather your own conclusions. We also encourage you to acquire a copy of the “confidential” pilot study results.

You may reach out to any of our Board member company representatives if you wish to have further discussions involving the most significant issue facing our industry in the past forty plus years. Millions of dollars have been spent on this issue by CMS and others. Other proposals, as mentioned prior, do exist. We by no means think that we (or anyone) have the perfect ultimate answer today. That said, we do believe that there are many great minds in our profession across the country and with true open discussion and collaboration we can create a promising future that supports the triple aim of healthcare.

What is Healthcare Reform?

According to the Institute for Healthcare Improvement (IHI), health care reform consists of the following three focus areas known as the triple aim of healthcare:

  1. Improve patient experiences (satisfaction, quality and outcome)
  2. Decrease cost
  3. Improve population health

triple aim of healthcare

Many have predicted that in future years this will result in bundled payment/episodic care.

Therapists deserve a seat at that payment reform table and there are many more suitable options than what is being endorsed by the APTA and working its way through the AMA committee process.

Introduction

First, a quick introduction. We (the APTQI) are among the nation’s leading providers of outpatient rehabilitation care, and collectively employ or represent several thousand physical and occupational therapists, and furnish physical therapy services on an annual basis to hundreds of thousands of Medicare beneficiaries.

What do we support?

We support reform initiatives in alignment with the Triple Aim of Healthcare and a transparent health care environment.

We support Physical and Occupational Therapy as a lower cost alternative to other options (imaging, surgery, medications) which is consistent with the ACA healthcare reform law that encourages less costly interventions and results in improved patient reported outcomes.

We believe our position is also consistent with the Physical Therapy Business Alliance (PTBA) position which can be found here.

We support moving away from regulatory administrative burdens that impact our clinicians and moving towards incorporating value, quality, clinical complexity and clinical judgment.

We support the premise that PT/OT services are a key component in the continuum of care.

We believe that to obtain the best seat at the table in negotiating for these services in any current or future episodic care or ACO environment, we must demonstrate quality care delivery, successful patient reported outcomes and exceptional patient experiences.

We believe that any transformational payment reform should be successfully piloted for reliability and validity as well as financially modeled.

We have been told on multiple occasions by the APTA “the APS coding and payment reform train has left the station and you better get on Board.”   We support transparency and collaboration in the process beyond lectures at conferences and this level of communication to its members. Transparency means more than patronizing lectures.

We believe the APTA’s effort at driving payment reform is a fear based and strategy decision (if we don’t do it someone else will and that will be bad) that wrongly assumes consolidating misvalued codes into an alternative fee for service system will somehow make coding valuation a non-issue for CMS and commercial payors.

We believe there may be some issues with the current therapy coding system, but we are not aware of any study that substantiates the degree of variability noted with the Proposed APS CPT Codes. In any case, transforming the “current fee for service” CPT therapy coding system with an “unreliable and subjective fee for service system” that does not consider quality and outcomes is strategically flawed.

We believe that all of the above are important to consider across all practice settings (private practice, acute care, skilled nursing, etc.) as any risk, benefit or change will result in an impactto all.

Last, but most certainly not least, we FULLY support our employees’ professional development in numerous areas as evidenced by our support of continuing education, Board Certifications, etc.