Taking it to the Steps
Monday January 23, 2012
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When patients are hit with $50 to $70 copays every time they visit physical therapists, the value of therapy comes under scrutiny. As more states see these copays rise, this has become a key issue for the profession's advocates on national and state levels as they set packed legislative agendas for 2012.
"We have a number of states where this will be a primary priority for the state legislative sessions of 2012," said Justin Moore, PT, DPT, vice president of government and payment advocacy for the American Physical Therapy Association. "What you're seeing is the copayment represents a significant portion of what is the payable service. If the insurer was only paying $72 for the visit and you're charging a $50 copay, the consumer is absorbing two-thirds of the cost."
According to Larry Benz, DPT, ECS, OCS, a member of the board of the Physical Therapy Business Alliance (ptballiance.org), PTs can expect a strong push on their behalf in 2012 to rectify out-of-whack copays and payment discrepancies. "There's a real dichotomy in the reimbursement world between what physical therapy is paid for in a hospital setting, known as provider-based reimbursement, versus the outpatient world, which falls under a fee schedule," Benz said.
PTBA an organization formed last year to protect the business interests of primarily private-practice PTs and to increase access. The stated mission of the group is to help state and federal legislators make informed decisions about access, reimbursement and regulatory issues.
"Private practice physical therapy is a great value, and we're often able to do it at a lower cost than our hospital counterparts. However, unfortunately, our reimbursement is often half or 30% to 40%" of the reimbursement rate for the same services in a hospital setting, Benz said. "You're going to see initiatives that try to equate provider-based reimbursement with free-standing outpatient."
The good fights
Here are some of the other battles ahead in 2012:
Direct access: The two states in which patients can't visit a PT without a physician's referral are Indiana and Alabama, so resources will be channeled to bring them in line with the rest of the country.
There's good news in this decades-long struggle, with a major new study published online Sept. 23, 2011, in the journal Health Services Research showing patients who visited a PT directly for outpatient care had fewer visits and lower average overall costs than those who were referred by a physician, Moore said. In the 62,707 cases studied, there was no significant difference in healthcare use in the 60 days after the physical therapy episode. Researchers wrote that "Healthcare use did not increase in the self-referred group, nor was continuity of care hindered. ... The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses and continuity of care for individuals who self-refer may be overstated."
Repeal of therapy cap: A continuation of the exceptions process to the therapy cap until Feb. 29 was passed late in 2011. Therapy caps are the $1,880 per-person annual limit Congress has placed on Medicare spending for physical therapy and speech language pathology combined. Because of complaints that some people need extensive therapy and will ration themselves if they aren't covered, exceptions have come into play.
"Repeal is probably not going to be possible until there's a new payment system, and we're two to three years from that being implemented by Medicare or other payors," Moore said. "We are advocating a new payment system … that would appropriately pay for PT services." Meanwhile, a bill that would repeal the cap outright has cosponsors in both the House and Senate — The Medicare Access to Rehabilitation Services Act, H.R. 1546/S. 829. But the differences remain large over how to pay for the deal.
Concussion guidelines: Awareness about childhood concussions has heightened in the past year-and-a-half with the Centers for Disease Control and Prevention estimating American children suffer as many as 3.8 million sports-related concussions each year.
The number of states passing legislation intended to protect young athletes from concussions has doubled in the past year, but unfortunately they vary widely, said Nate Thomas, PT, DPT, MBA, associate director of federal government affairs for APTA. There also are new policies coming from individual schools up to the federal level.
At the national level, H.R. 469 would make sure PTs are included in the list of providers who could decide when a youth athlete needs to sit out, how he or she needs to be treated and when the athlete can return to play. Without such legislation, PTs could be excluded from the group of decision makers in an athlete's care, even though a PT may have specialized knowledge critical to care. "There needs to be a team of providers. There could be psychological issues, neuro-psychological issues, that even a trained physician will not pick up on. There could be vestibular balance issues and a physical therapist would be the one who primarily sees them for this issue," Thomas said.
Student loan forgiveness: "It remains a federal priority for APTA to seek ways to enhance the physical therapy workforce and one of the primary ways to do that at the federal level … is student loan repayment opportunities," Thomas said.
The primary program for this is the National Health Service Corps, which enables healthcare providers to receive $60,000 in student loan repayment (over two years) to work in underserved areas. Legislation in the House — H.R. 1426 — would make PTs eligible for those funds. "Ultimately that will increase access in those areas where the need is currently not being met," Thomas said. It also would go a long way toward helping PTs whittle down their debt. An APTA survey of recent graduates found the average student loan debt was $96,149.
POPTS (physician-owned physical therapy services): APTA's position is that a PT may not accept a paycheck from the same person from whom they get a referral because that is an inherent conflict of interest. A physician, podiatrist or dentist can benefit financially from referral by having total or partial ownership of a physical therapy practice, directly employing PTs or contracting with PTs.
"There are five states that have some sort of law on their books that prohibits physician employment of PT services," said Justin Elliott, director of state government affairs for APTA. APTA is gearing up to defend the laws in California and South Carolina. "In 2006, the South Carolina Supreme Court upheld the South Carolina law that said no physical therapist may be employed by a physician. Every year since then, there's been an attempt to repeal [that] law and we expect another attempt in 2012," he said.
The other three states are Colorado, Delaware and Missouri.
Defending physical therapy under Medicaid: Since the recession began, physical therapy has been on the chopping block for states staring down billion-dollar budget gaps, Elliott said. Physical therapy is considered an optional service under Medicaid, and therefore a prime target for cuts.
"We've been pretty successful in defending PT under Medicaid in most states, but that is still a challenge," Elliott said. "For example, we've already heard that in Maine, PT is on the cutting block. As we start to see state budget bills, we'll have to go to the mat once again."
Beyond individual legislative efforts, APTA has a primary focus this year on educating members about how accountable care organizations will work and how PTs can be part of that model. Advocacy for these roles will come through the organizations putting them together — mainly hospitals in major healthcare systems.
"The biggest one we're looking at is the implementation of healthcare exchanges. States are under a deadline to start getting their health insurance exchanges up and running. If states don't start their own exchanges, the federal government will step in and they will have to go with the federal government's model," Elliott said. •
Marcia Frellick is a freelance writer.
"We have a number of states where this will be a primary priority for the state legislative sessions of 2012," said Justin Moore, PT, DPT, vice president of government and payment advocacy for the American Physical Therapy Association. "What you're seeing is the copayment represents a significant portion of what is the payable service. If the insurer was only paying $72 for the visit and you're charging a $50 copay, the consumer is absorbing two-thirds of the cost."
According to Larry Benz, DPT, ECS, OCS, a member of the board of the Physical Therapy Business Alliance (ptballiance.org), PTs can expect a strong push on their behalf in 2012 to rectify out-of-whack copays and payment discrepancies. "There's a real dichotomy in the reimbursement world between what physical therapy is paid for in a hospital setting, known as provider-based reimbursement, versus the outpatient world, which falls under a fee schedule," Benz said.
PTBA an organization formed last year to protect the business interests of primarily private-practice PTs and to increase access. The stated mission of the group is to help state and federal legislators make informed decisions about access, reimbursement and regulatory issues.
"Private practice physical therapy is a great value, and we're often able to do it at a lower cost than our hospital counterparts. However, unfortunately, our reimbursement is often half or 30% to 40%" of the reimbursement rate for the same services in a hospital setting, Benz said. "You're going to see initiatives that try to equate provider-based reimbursement with free-standing outpatient."
The good fights
Here are some of the other battles ahead in 2012:
Direct access: The two states in which patients can't visit a PT without a physician's referral are Indiana and Alabama, so resources will be channeled to bring them in line with the rest of the country.
There's good news in this decades-long struggle, with a major new study published online Sept. 23, 2011, in the journal Health Services Research showing patients who visited a PT directly for outpatient care had fewer visits and lower average overall costs than those who were referred by a physician, Moore said. In the 62,707 cases studied, there was no significant difference in healthcare use in the 60 days after the physical therapy episode. Researchers wrote that "Healthcare use did not increase in the self-referred group, nor was continuity of care hindered. ... The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses and continuity of care for individuals who self-refer may be overstated."
Repeal of therapy cap: A continuation of the exceptions process to the therapy cap until Feb. 29 was passed late in 2011. Therapy caps are the $1,880 per-person annual limit Congress has placed on Medicare spending for physical therapy and speech language pathology combined. Because of complaints that some people need extensive therapy and will ration themselves if they aren't covered, exceptions have come into play.
"Repeal is probably not going to be possible until there's a new payment system, and we're two to three years from that being implemented by Medicare or other payors," Moore said. "We are advocating a new payment system … that would appropriately pay for PT services." Meanwhile, a bill that would repeal the cap outright has cosponsors in both the House and Senate — The Medicare Access to Rehabilitation Services Act, H.R. 1546/S. 829. But the differences remain large over how to pay for the deal.
Concussion guidelines: Awareness about childhood concussions has heightened in the past year-and-a-half with the Centers for Disease Control and Prevention estimating American children suffer as many as 3.8 million sports-related concussions each year.
The number of states passing legislation intended to protect young athletes from concussions has doubled in the past year, but unfortunately they vary widely, said Nate Thomas, PT, DPT, MBA, associate director of federal government affairs for APTA. There also are new policies coming from individual schools up to the federal level.
At the national level, H.R. 469 would make sure PTs are included in the list of providers who could decide when a youth athlete needs to sit out, how he or she needs to be treated and when the athlete can return to play. Without such legislation, PTs could be excluded from the group of decision makers in an athlete's care, even though a PT may have specialized knowledge critical to care. "There needs to be a team of providers. There could be psychological issues, neuro-psychological issues, that even a trained physician will not pick up on. There could be vestibular balance issues and a physical therapist would be the one who primarily sees them for this issue," Thomas said.
Student loan forgiveness: "It remains a federal priority for APTA to seek ways to enhance the physical therapy workforce and one of the primary ways to do that at the federal level … is student loan repayment opportunities," Thomas said.
The primary program for this is the National Health Service Corps, which enables healthcare providers to receive $60,000 in student loan repayment (over two years) to work in underserved areas. Legislation in the House — H.R. 1426 — would make PTs eligible for those funds. "Ultimately that will increase access in those areas where the need is currently not being met," Thomas said. It also would go a long way toward helping PTs whittle down their debt. An APTA survey of recent graduates found the average student loan debt was $96,149.
POPTS (physician-owned physical therapy services): APTA's position is that a PT may not accept a paycheck from the same person from whom they get a referral because that is an inherent conflict of interest. A physician, podiatrist or dentist can benefit financially from referral by having total or partial ownership of a physical therapy practice, directly employing PTs or contracting with PTs.
"There are five states that have some sort of law on their books that prohibits physician employment of PT services," said Justin Elliott, director of state government affairs for APTA. APTA is gearing up to defend the laws in California and South Carolina. "In 2006, the South Carolina Supreme Court upheld the South Carolina law that said no physical therapist may be employed by a physician. Every year since then, there's been an attempt to repeal [that] law and we expect another attempt in 2012," he said.
The other three states are Colorado, Delaware and Missouri.
Defending physical therapy under Medicaid: Since the recession began, physical therapy has been on the chopping block for states staring down billion-dollar budget gaps, Elliott said. Physical therapy is considered an optional service under Medicaid, and therefore a prime target for cuts.
"We've been pretty successful in defending PT under Medicaid in most states, but that is still a challenge," Elliott said. "For example, we've already heard that in Maine, PT is on the cutting block. As we start to see state budget bills, we'll have to go to the mat once again."
Beyond individual legislative efforts, APTA has a primary focus this year on educating members about how accountable care organizations will work and how PTs can be part of that model. Advocacy for these roles will come through the organizations putting them together — mainly hospitals in major healthcare systems.
"The biggest one we're looking at is the implementation of healthcare exchanges. States are under a deadline to start getting their health insurance exchanges up and running. If states don't start their own exchanges, the federal government will step in and they will have to go with the federal government's model," Elliott said. •
Marcia Frellick is a freelance writer.
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Monday January 23, 2012