Private Practice Physical Therapists in Washington DC

The recent trip to Washington DC on the 23rd of July 2013 with the Private Practice Section (PPS Fly In) of the American Physical Therapy Association (APTA) to advocate for permanent repeal and replacement of the Medicare Sustainable Growth Rate (SGR) and overturn of the Therapy Cap.

Kerry (in this photo) also had the 'pleasure' of learning about Medicare Opt Out for physical therapists from us :)



From left to right:  Shamsah Shidi, PT,

Kerry L. Allen (Legislative Aide to Senator Bill Nelson)

Tim Richardson, PT

This next photo is in Congressman Vern Buchanan's office where Shane and I have met on many previous occasions.



Left to Right

Tim Richardson PT

Shamsah Shidi, PT

ShaneLieberman, (Legislative Director for Congressman Vern Buchanan)

Jack Front, PT

In this next photo, Gus Bilirakis had just informed of the pending vote by the House Energy and Commerce Committee on SGR reform. Bilirakis predicted there would be no opposition. Ultimately, the bill passed by unanimous vote, 51-0 on July 31 and would then move on to the full House.

Left to Right

Jack Front, PT

Congressman Gus Bilirakis

Shamsah Shidi, PT

Tim Richardson, PT

Sally Canfield of Senator Marco Rubio's office was present in 1997 when the original SGR formula was constructed. She resisted the temptation to wag her finger at her peers and politicos in Washington DC to say 'I told you so!'. Sally was probably the most well-informed and optimistic of all the congressional aides we spoke to that day.

Left to right:
Jack Front, PT
Shamsah Shidi, PT
Sally Canfield (Deputy Chief of Staff for Policy for Senator Marco Rubio
Tim Richardson, PT

I urge every physical therapist to leave your offices every now and then to get to know your legislators and advocate for physical therapists' patients. These people may control an important part of our future.

What has the American Physical Therapy Association done for you lately?

Patient stories...

Physical therapists hear these stories every day but the APTA is helping to put patient stories where they will do some good - in front of legislators who can determine your Medicare reimbursement.

The APTA coordinated a recent practice visit with the office of Federal legislator Vern Buchanan (R-Bradenton) on Tuesday, August 6th at a private physical therapy clinic in Bradenton, Florida. The following stories are a good example of what the legislator heard that day...

The 82-year old female patient gave a lucid, moving story about how her physical therapist had 'saved her life' by helping her remain living at home after a fall and a hip fracture. She mentioned she was already at the 'hard cap' of $3,700 in 2013 and didn't know how she could continue to pay for the services of her therapist even at the reduced frequency of one time per week.

The male patient, a retired veterinarian, told a very funny story of dislocating his shoulder by, believe it or not, walking his big dog. He was offered imaging and surgery by an orthopedic surgeon who owns therapy services. The patient said he wanted to think about these two options and, in the meantime, could he get a referral to physical therapy? That was three months ago and he now has full passive ROM. He is in no pain. He is also at the 'hard cap' but he credits his physical therapist with preventing what was, in his opinion, an unnecessary surgery.

Therapy Cap is top-of-mind for physical therapists because we deal with it every day but most legislators and their staff have many other responsibilities. Patient stories help make the recent Therapy Cap legislation REAL for members of the Congress by putting a human face on the problem.

The Medicare Access to Rehabilitation Services Act (HR 713) was recently introduced in the House of Representatives by Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA).  HR 713 would permanently repeal the $1,900 therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services.

We asked Congressman Buchanan to support HR 713 by attaching it to another bill that is gathering momentum in Washington DC.   The Medicare Physician Payment Innovation Act (HR 574), introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV) provides the following:

• repeal and replace the flawed Sustainable Growth Rate (SGR) formula.
• a clearly defined path to permanent Medicare payment reform.
• it includes a multi-year period of payment stability for Medicare providers.
• a stipulated annual payment rate increase of 0.5% to the Physician Fee Schedule.
• CMS will test and evaluate several alternative payment systems including the Alternative Payment System for therapy proposed by the American Physical Therapy Association. 

For the first time in many years, there is bipartisan support for repealing and replacing the SGR and fixing Medicare reimbursement for physical therapists via HR 574.  There is also a chance to fix the Therapy Cap by attaching HR 713.

To improve our chances you need to contact your legislators with your patient stories.   

Justify your Physical Therapy

How do you 'justify' your physical therapy?

How do you 'prove' that your patient needs physical therapy and is benefiting from your care.

Many physical therapists think that the patients verbal statements "I feel better!" placed in the written chart is sufficient to justify services to Medicare patients.

Many therapists use a simple outcome measure to show progress and demonstrate need.

Is one simple outcomes measure and patient "subjective" statements sufficient to exceed the $1,840 therapy cap?

Probably not.

Centers for Medicare and Medicaid (CMS) Transmittal 88 states the following:

"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed."(p.23)

A narrative is a statement that says "Here is why I am putting the '-KX' modifier on my charges - here is why I think my patient qualifies for Medicare Part B benefits over the therapy cap."

A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. (p.24)"

If the record justifies...

That is a big IF...

This Justification Statement is the one my facility uses to PROVE our patient deserves their rightful Medicare benefits.

It also protects me from unfair fines or repayments if I get audited.

Disclaimer: I am a physical therapist in private practice - not a Medicare auditor. You should make your own decision as to the veracity of my statements and the extent to which my recommendations fit with your own compliance program.
I do not give individual compliance advice.

Note in the Justification Statement how various levels of clinical evidence support and reinforce each other:

• outcomes measures
• performance measures
• impairment measures
• written patient statements

"Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus." (p.26)

Your patients deserve the therapy they need.

Some facilities automatically discontinue physical therapy when allowed charges hit $1,840 - regardless of whether patient goals are met.

Is that fair?

Spend Money on Health Care to Stimulate Demand

Physical therapists face a 15.1% pay cut in 2010.

Congress can prevent these cuts by voting to prevent an update to the much-hated Sustainable Growth Rate (SGR) portion of the physicians' fee schedule.

Why should Congress act on behalf of physical therapists?

Self-interest, to put it bluntly.

Congressional and American self-interest.

Physical therapy jobs are an important part of the United States economy.

Health care jobs are reponsible for half the job growth in the US economy since 2001.

"The good news is that if the housing market falls into a deep swoon,
health care could provide enough new jobs to prevent a wider recession."

But, the flip side of this upward trend is the larger trend of excessive US borrowing:

"...one explanation for the huge U.S. trade deficit is that the country is borrowing from overseas to fund creation of health-care jobs."

Uh oh, Congress is between a rock and a hard place!

What, you ask, will Congress do?

Well, your crystal ball is as good as mine is.

But, today's Online News Hour with Jim Lehrer spoke truth to power when, in the face of massive US job layoffs, the show's moderators advocate spending in order to 'elevate demand in the economy'.

Right now, the 2 trillion dollar US health care economy is 50% funded by the US government.

One specific reccomendation of the moderators...

• Spending money now on Electronic Medical Records (EMR) - expected 10-year return (according to Congressional Budget Office)= $90 billion.

Another spending item that will no doubt surface in discussions is the The Medicare Access to Rehabilitation Services Act (H.R.43/S.46) sponsored by the following:

• Congressmen Xavier Becerra (D-CA)
  
• Mike Ross (D-AR)
  
• Roy Blunt (R-MO)
  
• Senator John Ensign (R-NV)

In 2009, the therapy cap is an easy target that physical therapists need to popularize for the benefit of our patients.

It may seem opportunistic to exploit political circumstances for economic gain now but physical therapists must remember that, for too long, the policy-makers in Washington have exploited physical therapy patients and providers for such morally ambiguous concepts like 'budget neutrality'.

Act now and contact your congresswoman (or man) and ask them to suport H.R. 43/S. 46 .