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The Time to Act Is Now, Ask Congress to Stop Medicare Cuts

Published On 9.16.20

By Akshita Shetty, PT

Physical Therapist

By now, most clinicians have heard about the nine percent cuts proposed by the Center of Medicare and Medicaid Services (CMS) under the Medicare Physician Fee Schedule (PFS) to physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) taking effect in January 2021. Under normal circumstances, these cuts would be uncalled for, let alone during a pandemic when the health care system is already facing economic hardships.

So why is CMS taking these drastic steps? Let’s take a closer look at the factors shaping this policy and what we can do as professionals to effectively fight it.

Background of Medicare Physician Fee Schedule

Medicare transitioned to the Physician Fee Schedule (PFS) payment system in 1992. The PFS is a comprehensive list of fee maximums used to reimburse health practitioners providing services under Medicare. The American Medical Association (AMA) developed the Current Procedural Terminology (CPT) system, which is utilized by health care practitioners to report services provided to beneficiaries. Medicare, Medicaid, and private health insurers use the CPT system to process claims.

Each CPT code has a relative value unit (RVU) assigned to it. These RVUs are determined based on the time, skill, and training required to provide a service, cost of maintaining a practice, and professional liability expenses. These RVUs are then adjusted according to geographical practice cost indices. After that the adjusted RVUs are multiplied by the conversion factor, a national dollar amount set by the federal government, to determine the final payment to be made to the clinicians billing Medicare under the PFS. The conversion factor is updated on an annual basis.

Budget Neutrality Rule

According to the American Journal of Neuroradiology, CMS cannot increase or decrease total spending greater than 20 million dollars of the overall budget as required by the Social Security Act of 1848.

In an effort to improve outcomes for patients with chronic conditions, such as diabetes and hypertension, the AMA recommended an increase in evaluation and management (E/M) codes billed by physicians to:

  1. Reflect the resources required in providing an E/M visit
  2. Decrease administrative burden
  3. Increase one-on-one time with patients

Despite strong advocacy from the American Physical Therapy Association (APTA), American Occupational Therapy Association (AOTA), and American Speech-Language-Hearing Association (ASHA), CMS, obliged by the budget neutrality rule, announced a decrease in the 2021 conversion factor owing to the nine percent cuts. The budget neutrality rule can only be waived by Congress.

What action is currently being taken against the CMS cuts?

Advocacy matters a great deal. It is because of the tiresome efforts of strong advocates in our profession that 93 members of Congress signed a bipartisan letter on August 11th highlighting the negative impacts of the cuts that will be faced by an already strained health care system. The letter accurately stresses the adverse effects these cuts will have on health care access. In the letter, members ask Congress to waive budget neutrality rules for calendar years 2021 and 2022. They also ask Congress to require CMS to review how COVID-19 has impacted access to critical health services in underserved areas and the magnitude of damage it will cause to health care if budget neutrality requirements are not waived.

Due to the ongoing efforts of APTA, ASHA, AOTA, and other health organizations, the U.S. House of Representatives released a bipartisan bill known as the Outpatient Therapy Modernization and Therapy Stabilization Act. This bill, if passed by Congress, would permanently waive budget neutrality requirements for CMS. It would also allow PTs, OTs, and SLPs to become permanent telehealth providers even after the national health emergency ends.

How can clinicians, students, and patients help?

Why does Congress need to hear from every single one of us?

The increase in the value of E/M visits billed by physicians is a positive change and will improve patient outcomes. However, Congress needs to know that it is counterproductive to decrease reimbursement to the providers who are skilled in evaluating, assessing, and screening patients with chronic conditions. This will only hinder patient access to PT, OT, and SLP services and increase long term health care costs.

Even though our professional organizations have made it very convenient to send pre-written messages to our legislators, we need to personalize them to underscore the magnitude of the negative impact the cuts will have on health care delivery and health care costs.

A study commissioned by the Alliance for Physical Therapy Quality and Innovation (APTQI) was focused on Medicare claims from beneficiaries with a diagnosis of low back pain. The results concluded that choosing physical therapy as the first line of treatment decreased costs by 19 percent of average as compared to the injections-first group and 75 percent lower than the costs of the surgery-first group.

In letters to Congress, it is important to relay the impact of the COVID-19 pandemic on public health. To curtail the spread of COVID-19, social and physical distancing measures were enforced that are in effect to this date. The pandemic forced many older adults to stay indoors in isolation for several months now in order to prevent the risk of infection. The outbreak stopped many individuals from going to rehabilitation clinics and refusing home visits due to fear of contracting the virus. Furthermore, as necessary precautions, local gyms and exercise spaces within residences were closed. A few residences prohibited people from taking walks in their hallways increasing inactivity levels in the community.

A study emphasizes the impact of physical inactivity on muscle strength, walking speed, and muscle mass leading to falls and injury. The study focuses on the cost-effectiveness of a patient-centered physical therapy program and its ability to decrease negative health outcomes of frailty.

Due to the novelty of the virus, research on COVID-19 is constantly evolving. According to a recent report in JMIR Public Health and Surveillance, COVID-19 survivors are likely to suffer from long term effects of intubation and ventilation. These include critical illness myopathy, critical illness polyneuropathy, and post ICU syndrome. Patients are also likely to develop:

  • Associated cardiac injury
  • Neurological consequences such as headache, confusion, seizures, and visual loss
  • Cognitive sequelae such as impairments in attention, visual-spatial abilities, working memory, and executive function
  • Psychosocial sequelae, such as anxiety, depression, mood disturbances, and post-traumatic stress disorder

These complications only just begin to indicate the long road to recovery requiring a multidisciplinary rehabilitation approach. Ideally, this approach will have PTs focusing on muscle strength and endurance, postural control and ambulation; OTs helping patients with activities of daily living to promote functional independence, and SLPs treating patients for dysphagia and voice impairments as a consequence of prolonged intubation.

Our professional organizations need us, how can we help?

The importance of becoming a member of your professional organization cannot be stressed enough. APTA, AOTA, and ASHA use all their resources to advocate for and uplift their respective professions.

Being a part of these associations helps us stay up to date with current legislation regarding our profession, gives us access to evidence-based practice, and presents us with multiple opportunities to join advocacy networks. This will bolster our ability to uplift our own respective professions. Becoming a member allows us to make donations to political action committees (PACs) as well. Members can donate to PT-PAC, AOTPAC, and ASHA-PAC.

Here are five reasons to donate to your PAC:

  1. PACs use monetary contributions to fund federal candidates that further legislative interests in support of policies that strengthen our profession and ability to deliver high-quality services to our patients.
  2. PACs focus their efforts on building strong relationships with members of Congress and their staff.
  3. Due to federal regulations, APTA, ASHA, and AOTA are prohibited from using membership dues to support federal candidates. PACs are funded solely through individual contributions. Every dollar counts.
  4. According to the 2018 election cycle, PT-PAC, AOTPAC, and ASHA-PAC are among the top 30 health care associations to raise federal candidate contributions.
  5. PACs identify potential candidates after extensive research and evaluation based on past and current leadership roles and stances on various health care policies to ensure the best interest of providers and patients.

Let’s spread the word!

We need to involve our patients and caregivers. They value our services and notice improvements in function from everyday care. We need to ask them to share their functional gains with members of Congress.

Reach out to students who will soon be graduating to become PTs, OTs, and SLPs. Urge them to send letters to their representatives. The time is crucial and we need to advocate strongly and raise awareness of the importance of our profession to build strong communities.

There is strength in numbers and every voice counts, so make yourself heard!

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