Outcome oriented
Monday September 3, 2012
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If you live in a swing state, it’s impossible to turn on the television without being bombarded with campaign ads — for the presidency and other races. Who will control Congress? Who will live in the White House? Much is at stake for healthcare providers, including physical therapists, and much needs to take place before the end of the year or PTs will face significant cuts in reimbursement.
"We’re not so concerned if the Republicans or Democrats win, but can they come together to address these issues," said Mandy Frohlich, senior director of government affairs at the nonpartisan American Physical Therapy Association, based in Alexandria, Va.
On the other hand, Jerry Connolly, Capitol Hill lobbyist for PTPN, a network of PTs in private practice, expects different ramifications for PTs depending on what happens in November — if Congress and the presidency remain as they are today, which will maintain the status quo; if the president is elected but Republicans gain control of the Senate; or if the Republicans gain the Senate and White House. The latter two scenarios will lead to more uncertainty for PTs and other providers.
"While elections are never without implications, this one has serious implications for the immediate and long-term future of healthcare professionals, particularly physical therapists," Connolly said.
Uncertainty may linger
"The Affordable Care Act, which is now the law of the land, is changing the environment for all healthcare providers," Connolly said.
Republicans’ stump-speech rhetoric includes repealing the ACA, which could include many of the provisions already in place and saving people money. "The results of the election will dictate the degree to which they can follow through with those promises and pledges to repeal," said Connolly. "There are a ton of things in it for physical therapists."
The Republican presidential candidate has pledged to work with Congress to repeal the full ACA as quickly as possible after taking office, according to his MittRomney.com website. In addition, Speaker of the House John Boehner, R-Ohio, issued a statement after the Supreme Court upheld the ACA that the "ruling underscores the urgency of repealing this harmful law in its entirety." However, Connolly said, they may have difficulty since many of the provisions already are in place and saving people money.
Since the ACA was enacted, seniors and people with disabilities have saved $3.9 billion on prescription drugs as the law began closing the "doughnut hole" coverage gap, according to the U.S. Department of Health and Human Services. The requirement that insurance companies must spend 80% of premiums on medical care and quality or return the portion exceeding that limit to the purchaser of the policy will provide 12.8 million Americans $1.1 billion in rebates from insurance companies this summer. The per-family rebate averages $151 across all markets. But families in Vermont with large group coverage will receive, on average, $807; in Oregon, $777; and in Indiana, $503. In the small market group, those in Georgia will receive $811; in Ohio, $783; and in New York, $632, according to the Centers for Medicare and Medicaid Services.
"It’s not going to be easy, but if they repeal all or part of it, it creates a degree of uncertainty, a Wild West," Connolly said.
Meghan Finegan, spokeswoman for the Service Employees International Union, representing some hospital-based PTs, said she hopes that those elected in the fall do not repeal the ACA. "We do not want to see 32 million Americans lose coverage or their insurance protections taken away," Finegan said.
APTA does not hold a position on the ACA, Frohlich said, but the inclusion of rehabilitation in the essential health benefits package is a benefit to PTs.
"There are a number of things, on and on, that are beneficial," Connolly added. "Some things are not as attractive, but on balance, the things in effect now and continuing to move forward to be in effect next year and the year after are shaping the healthcare delivery system to put more emphasis on the value of healthcare and less on the volume. That should be a welcome concept for physical therapists because they have been delivering high-value care for decades."
Some lessons can be learned from Massachusetts, which pioneered a universal healthcare system that in many ways is similar to the ACA.
"The landscape is changing in Massachusetts, as it’s changing nationally," said Matt McManus, PT, co-owner of ProEx Physical Therapy in Boston and co-chairman of the APTA of Massachusetts payment and policy committee. "Massachusetts is a little ahead of the curve. There is still a strong movement locally and nationally on patient satisfaction and cost effectiveness. And a lot of us are trying to drive those metrics with our patients."
Alternative delivery systems, such as accountable care organizations, one of the major provisions of the bill, will require the healthcare industry to move toward a more collaborative, communicative delivery model. The private sector already is moving in this direction. "Any therapist able to demonstrate quality of their care, the status of their patients, patient satisfaction and lower cost, will not be adversely affected," Connolly said. PTs not invited to join an ACO will need to market directly to consumers who will have a choice of providers.
Direct access
Another issue of concern to APTA is direct access, allowing patients to consult a PT without a referral from a physician, and receiving reimbursement for that. Frohlich said 49 states, all but Indiana, allow direct access, but Medicare, Medicaid and many private payors do not reimburse without a physician’s signature on a plan of care. "We want patients to see a physical therapist without seeing a doctor first," she said. "We have to work on the regulatory and legislative side to make sure it matches that goal."
McManus added that PTs could be the preferred provider for nonsurgical orthopedic situations. "Early immediate access can cost-contain and control some of the expenses," he said.
Year-end issues
Direct access is not the only reimbursement issue of concern to PTs. The failure of the congressional "super committee" to reduce the budget has resulted in a sequestration process, which would result in cuts in all federal departments, including a 2% across-the-board decrease in Medicare payments to providers. APTA is lobbying Congress to pass legislation before Dec. 31 to exempt physical therapy from the reduction.
"There will be a push at the end of this year to work with the federal government to decide if there’s a way to find those cost savings in other places," Frohlich said.
Also looming on Jan. 1 is the expiration of the sustainable growth rate. PTs are paid on the same fee schedule as physicians and fall under the SGR provision. Since 2003, Congress has passed various legislation to override the cuts, according to a report from the Congressional Research Service, but has not replaced the SGR formula or enacted a long-term solution to the flawed system. APTA is asking Congress to again pass legislation to avoid an estimated 27% to 30% reimbursement cut set to go into effect in January.
The therapy cap extension also comes due at the end of the year. In 1997, Medicare put a limit on the amount of physical therapy a beneficiary can receive, and since then Congress has authorized exceptions.
"Those are the big three [policy issues] that will affect physical therapy," Frohlich said.
Connolly said he expects no action on these issues or other major items now pending, such as the expiring Bush tax cuts, the alternative minimum tax and other provisions. All will wait until the postelection lame-duck session. "Everything with respect to Medicare hinges on the outcome of the election," he said. If the status quo prevails, he expects the Democrats will lean on Republicans to address these issues. However, if the Republicans take over the Senate and White House, he expects they will want to postpone these issues until they can make decisions.
APTA will put its advocacy network, PTeam, to work contacting members of Congress soon after the election to help move forward issues that need resolution by year-end. "We need more of us with boots on the ground to be involved in advocacy," said McManus. "We need our membership to step up, unify and talk to legislators." •
Debra Wood is a freelance writer.
"We’re not so concerned if the Republicans or Democrats win, but can they come together to address these issues," said Mandy Frohlich, senior director of government affairs at the nonpartisan American Physical Therapy Association, based in Alexandria, Va.
On the other hand, Jerry Connolly, Capitol Hill lobbyist for PTPN, a network of PTs in private practice, expects different ramifications for PTs depending on what happens in November — if Congress and the presidency remain as they are today, which will maintain the status quo; if the president is elected but Republicans gain control of the Senate; or if the Republicans gain the Senate and White House. The latter two scenarios will lead to more uncertainty for PTs and other providers.
"While elections are never without implications, this one has serious implications for the immediate and long-term future of healthcare professionals, particularly physical therapists," Connolly said.
Uncertainty may linger
"The Affordable Care Act, which is now the law of the land, is changing the environment for all healthcare providers," Connolly said.
Republicans’ stump-speech rhetoric includes repealing the ACA, which could include many of the provisions already in place and saving people money. "The results of the election will dictate the degree to which they can follow through with those promises and pledges to repeal," said Connolly. "There are a ton of things in it for physical therapists."
The Republican presidential candidate has pledged to work with Congress to repeal the full ACA as quickly as possible after taking office, according to his MittRomney.com website. In addition, Speaker of the House John Boehner, R-Ohio, issued a statement after the Supreme Court upheld the ACA that the "ruling underscores the urgency of repealing this harmful law in its entirety." However, Connolly said, they may have difficulty since many of the provisions already are in place and saving people money.
Since the ACA was enacted, seniors and people with disabilities have saved $3.9 billion on prescription drugs as the law began closing the "doughnut hole" coverage gap, according to the U.S. Department of Health and Human Services. The requirement that insurance companies must spend 80% of premiums on medical care and quality or return the portion exceeding that limit to the purchaser of the policy will provide 12.8 million Americans $1.1 billion in rebates from insurance companies this summer. The per-family rebate averages $151 across all markets. But families in Vermont with large group coverage will receive, on average, $807; in Oregon, $777; and in Indiana, $503. In the small market group, those in Georgia will receive $811; in Ohio, $783; and in New York, $632, according to the Centers for Medicare and Medicaid Services.
"It’s not going to be easy, but if they repeal all or part of it, it creates a degree of uncertainty, a Wild West," Connolly said.
Meghan Finegan, spokeswoman for the Service Employees International Union, representing some hospital-based PTs, said she hopes that those elected in the fall do not repeal the ACA. "We do not want to see 32 million Americans lose coverage or their insurance protections taken away," Finegan said.
APTA does not hold a position on the ACA, Frohlich said, but the inclusion of rehabilitation in the essential health benefits package is a benefit to PTs.
"There are a number of things, on and on, that are beneficial," Connolly added. "Some things are not as attractive, but on balance, the things in effect now and continuing to move forward to be in effect next year and the year after are shaping the healthcare delivery system to put more emphasis on the value of healthcare and less on the volume. That should be a welcome concept for physical therapists because they have been delivering high-value care for decades."
Some lessons can be learned from Massachusetts, which pioneered a universal healthcare system that in many ways is similar to the ACA.
"The landscape is changing in Massachusetts, as it’s changing nationally," said Matt McManus, PT, co-owner of ProEx Physical Therapy in Boston and co-chairman of the APTA of Massachusetts payment and policy committee. "Massachusetts is a little ahead of the curve. There is still a strong movement locally and nationally on patient satisfaction and cost effectiveness. And a lot of us are trying to drive those metrics with our patients."
Alternative delivery systems, such as accountable care organizations, one of the major provisions of the bill, will require the healthcare industry to move toward a more collaborative, communicative delivery model. The private sector already is moving in this direction. "Any therapist able to demonstrate quality of their care, the status of their patients, patient satisfaction and lower cost, will not be adversely affected," Connolly said. PTs not invited to join an ACO will need to market directly to consumers who will have a choice of providers.
Direct access
Another issue of concern to APTA is direct access, allowing patients to consult a PT without a referral from a physician, and receiving reimbursement for that. Frohlich said 49 states, all but Indiana, allow direct access, but Medicare, Medicaid and many private payors do not reimburse without a physician’s signature on a plan of care. "We want patients to see a physical therapist without seeing a doctor first," she said. "We have to work on the regulatory and legislative side to make sure it matches that goal."
McManus added that PTs could be the preferred provider for nonsurgical orthopedic situations. "Early immediate access can cost-contain and control some of the expenses," he said.
Year-end issues
Direct access is not the only reimbursement issue of concern to PTs. The failure of the congressional "super committee" to reduce the budget has resulted in a sequestration process, which would result in cuts in all federal departments, including a 2% across-the-board decrease in Medicare payments to providers. APTA is lobbying Congress to pass legislation before Dec. 31 to exempt physical therapy from the reduction.
"There will be a push at the end of this year to work with the federal government to decide if there’s a way to find those cost savings in other places," Frohlich said.
Also looming on Jan. 1 is the expiration of the sustainable growth rate. PTs are paid on the same fee schedule as physicians and fall under the SGR provision. Since 2003, Congress has passed various legislation to override the cuts, according to a report from the Congressional Research Service, but has not replaced the SGR formula or enacted a long-term solution to the flawed system. APTA is asking Congress to again pass legislation to avoid an estimated 27% to 30% reimbursement cut set to go into effect in January.
The therapy cap extension also comes due at the end of the year. In 1997, Medicare put a limit on the amount of physical therapy a beneficiary can receive, and since then Congress has authorized exceptions.
"Those are the big three [policy issues] that will affect physical therapy," Frohlich said.
Connolly said he expects no action on these issues or other major items now pending, such as the expiring Bush tax cuts, the alternative minimum tax and other provisions. All will wait until the postelection lame-duck session. "Everything with respect to Medicare hinges on the outcome of the election," he said. If the status quo prevails, he expects the Democrats will lean on Republicans to address these issues. However, if the Republicans take over the Senate and White House, he expects they will want to postpone these issues until they can make decisions.
APTA will put its advocacy network, PTeam, to work contacting members of Congress soon after the election to help move forward issues that need resolution by year-end. "We need more of us with boots on the ground to be involved in advocacy," said McManus. "We need our membership to step up, unify and talk to legislators." •
Debra Wood is a freelance writer.
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Monday September 3, 2012