By Tannus Quatre, PT, MBA
If you own or manage your business, you negotiate a lot. It is not just traditional contracts or formal agreements that I am talking about. I am talking about just about everything that has a desired outcome.
Whether discussing price with a vendor, compensation with an employee, or lease terms with your landlord, you are negotiating—you must remember this fact.
If you do not first acknowledge that you are in the midst of negotiation—and the person across the table does—you are apt to lose out on something you did not even know you could have been playing for. Ouch.
I do want to be clear however, that negotiating does not have to be a “zero sum” game—in fact, it really should not be. For you to win, someone else does not actually have to lose. The best negotiations result in wins for all parties—the prized outcome of all good negotiators.
And while win-win wins are the ultimate prize, the foremost goal should be to ensure you do not shortchange yourself. Walking away from a deal that did not have enough in it for you may carry some level of disappointment, but this is far better than the regret (or worse yet—the ignorance) of not getting your fair shake.
To protect yourself, I try to keep one principle at the forefront while negotiating. I listen.
Listening does not mean you do not have something to say. There are important aspects of negotiating that require you to plant your flag—making your stance be known. Do this too early though—especially before you know what makes your counterpart tick—and you have begun operating with limited knowledge. And knowledge is power when negotiating.
Talking compensation with an employee? Ask them what they are looking for; this will give you the opportunity to help them with a path toward that end.
Discussing price with a vendor? Give them some base parameters about what you are looking for (or can afford), and then let them fill in the blanks for how they can accommodate your needs.
Trying to agree on where to spend date night with your spouse? Well…I will let you handle that one (if anyone knows the formula for successfully pointing this to the football stadium, let me know).
Where flexibility is present—and most times there is —there are many paths to a desirable outcome. If you know how to use it, arming yourself with every bit of information you can uncover is going to work in your favor. Listening is a key tool.
Remember that it is not a criminal act to allow yourself every advantage you can get. If there is one thing we need in the physical therapy profession, it is the ability to give ourselves an edge. I will shut up now and let you do the same.
Tannus Quatre, PT, MBA, is a physical therapist and entrepreneur dedicated to improving the profession through innovative business and marketing solutions. His work can be seen in such projects as PT Pub Night® and BuildPT.com. He is president of Vantage Clinical Solutions and can be reached at firstname.lastname@example.org.
Corporate employee health is an opportunity for private practices.
Russell Certo, PT, OCS, and William McCormick, PT, MS, CSCS
At the 2014 Private Practice Section (PPS) meeting, it appeared that the general theme in many of the educational presentations was how primary orthopedic practices could expand their services to include medical fitness or general fitness exercise programs to their service offerings. There were many ideas as to how to best provide those services, including a small add-on fitness service with minimal disruption or, at the other extreme, provide employee wellness programs to corporate clients. Both the presenters and the participants discussed several strategies and business models. It was apparent that we are all trying to find ways in which we can expand our relevance/presence within the medical delivery system and grow our own businesses. One model or method to achieve this goal is developing a corporate employee health (CEH) program.
According to the Employee Benefit Research Institute 52 percent of employers are now self-insured companies.1 Because of certain provisions within the Affordable Care Act, it is estimated that over the next 5 years, 75 percent of all employees in the private sector will be covered by self-insured health insurance.2 Self-insured health insurance is simply an insurance product where the employer assumes the financial risk for providing health care benefits to its employees. In almost all cases, these companies contract the actual claims processing to a third-party administrator (such as Blue Cross). In an attempt to control the risk of health care claims, these employers have instituted “wellness” programs. However, many of these strategies do not measure outcomes and/or tie results to claims information. The most common form of wellness programming provided by the employer is an online health risk assessment (HRA) whereby the employee voluntarily answers a series of questions online and the software program provides an analysis and simple strategies for improving health risk markers. For example, if the employee smokes, the HRA suggest they stop smoking or if the employee has not had a yearly physical, the HRA suggests they visit their doctor for a physical. More sophisticated and robust “wellness” programs engage an outside contractor who analyzes claims history and the HRA information and provides the company with a snapshot of their employees’ overall health, creating general risk pools in which employees are placed. Additionally, the contractor is able to designate specific diagnoses or medical conditions of the employees that drive the health care claims cost higher.
In almost all instances, these self-insured employers are provided some data analysis by their third-party claims administrator or contractors but are never given appropriate or effective strategies for actually engaging employees in healthy lifestyles. We have identified this self-insured market as the greatest opportunity for growth for private practice physical therapy companies looking to provide medical exercise prescriptions. This opportunity exists for not only the single office practice but also for the multisite and large practices. We believe that physical therapy practices can become the “what’s next” solution for CEH programs. In the big picture, our practices can provide a meaningful fitness program that engages employees within individual companies, but we can also become partners with the third-party administrators that provide benefit coordination to many self-insured employers. In addition, these services provide us the opportunity to partner with the data analysis contractors who can then sell our interventions as part of their services to provide lifestyle management programs to the employee.
In the past 10 years, many of us have added fitness services to our primarily orthopedic practices by providing our discharged patients with a place to continue exercising. Many practices have used this service to expand into a cash-based business that supports the overall business model. Some of us have been able to develop diagnosis specific programs, partnering with primary care physician groups and growing our practices by as much as 30 percent because our referral base is larger and our footprint in our communities is bigger. Additionally, in our case, we have partnered with other private practices across the country to develop a network of like-minded practices that share our data, outcomes, successes, and even our failures. It is easy to find naysayers that say these add-on medical fitness programs have not been profitable for physical therapy businesses. Our experience has been that our fitness programs have been break-even propositions when looked at as a stand-alone entity. However, the medical fitness addition has increased our physical therapy income by 30-40 percent, providing a range of return on investment between 4:1 and 9:1 in some cases. Additionally, our partnerships with primary care physicians has made us more relevant in our local medical community, offering us new opportunities that we would not otherwise have had if we did not develop a fitness service.
In terms of the CEH program, we identified the larger self-insured employers and then subdivided that group into companies that had an onsite fitness center and those that did not provide onsite fitness. Marketing our experience in medical fitness and using our data, outcomes, and total-cost-of-care reductions collected over the past 10 years, we have been able to capture the attention of the decision makers at these companies. In general, we propose that these companies embed our employee in their fitness center, in some cases manage the fitness center for them, and begin to provide appropriate, effective, data driven exercise to their employees. We generally begin with a pilot program that identifies and engages the higher risk employees who are driving the health care claims higher. We have proven that our model of medical fitness will move employees from high-risk pools to moderate-risk pools and moderate-risk employees to low risk, potentially saving corporations hundreds of thousands of dollars annually. Our program not only includes exercise prescription but also provides educational seminars, nutritional information, and lifestyle management strategies that engage employees and retains 75 percent of the employees participating in the pilot program.
In terms of cost savings, there are obviously direct savings from a claims perspective but there will also be cost savings from the employer standpoint of reduced absenteeism, better productivity, and improved employee morale. For our physical therapy practice, we are able to create an income stream from the management of the onsite fitness center, individual payments for each employee enrolled, and over time, a shared savings model of payment. Also included in the income stream is the potential for additional physical therapy services at our clinic or onsite at the corporation.
For many of us, we have successfully tapped into the opportunities in our markets to provide outpatient orthopedic physical therapy services that are very traditional in nature. The old adage that “if you are not growing you are dying” is appropriate. We all recognize that if we do not adapt to changes in health care, we will become irrelevant and our business will struggle. As a group, we have realized that we can make a difference by providing appropriate exercise to medically compromised patients who cannot be served by the neighborhood fitness club and the local YMCA. We are the experts at delivering these medical fitness prescriptions and we are accepted members of the health care delivery system. Our growth in private practice for the single entity office and for the large multisite physical therapy business is in coordinating lifestyle management services that drive the cost of care down, flattening the cost curve, and sharing in those cost savings. These opportunities provide us another chance to serve our communities, work within the medical delivery system, and maintain our presence, relevance, and standing within that system.
Russell Certo, PT, OCS, of MOG at Grand Island Physical Therapy PC. He can be reached at email@example.com.
William McCormack MS, PT, CSCS, of MOG National. He can be reached at firstname.lastname@example.org.
1. Employee Benefit Research Institute. www.ebri.org/pdf/briefspdf/EBRI_IB_413_Apr15_RCS-2015.pdf. Accessed November 2015.
2. Employee Benefit Research Institute. www.ebri.org/pdf/briefspdf/EBRI_IB_413_Apr15_RCS-2015.pdf. Accessed November 2015.
If you have been to a national meeting, such as the Private Practice Section (PPS) Annual Conference, you have no doubt enjoyed the opportunity to exchange business ideas and stories with fellow members from around the country at the bar, over coffee, or in the exhibit hall between sessions. These conversations can be energizing, but then when you return to work after the conference, frustration ensues because you have difficulty setting into motion what you learned, heard, and/or discussed. You lack the support, accountability, and details, so you return to business as usual. You know there is a better way, but you just cannot figure it out on your own.
Recognizing this frustration and need the PPS board of directors, by a unanimous vote, approved the formation of the ground-breaking Mastermind Group program. In its quest to provide value and innovation to members so that they can stay ahead of the rapid changes in health care, the PPS board is continually proactive in identifying new ways to deliver value to members.
The Mastermind Group helps its members learn, improve, and achieve success. In the PPS version of the Mastermind Group, a professional facilitator will form groups of six to ten executives based on size and type of practice (among other factors). The groups will meet twice a year for structured face-to-face meetings. Content experts may be secured using PPS resources to provide education and stimulate discussion.
Participants challenge each other to question assumptions, assess strengths and weaknesses, set goals and, above all, accomplish those goals. Members support each other and hold each other accountable to those goals. The group requires trust, commitment, and confidentiality. Therefore, members are assigned to groups that do not include potential or current competitors.
Participation is interactive. Members give and receive advice and ideas. The groups learn and grow together, leveraging the unique strengths of each other as a willingness to ask probing questions and openly share experiences builds the foundation for mutual success.
The first meeting of the mastermind groups will take place in Alexandria, Virginia April 27 to 29, 2016. Groups are being formed now. Please visit the Private Practice Section (PPS) website or call the PPS office for more information and to complete an application. Once your application is received you will be contacted for a personal interview by the program facilitator. The purpose of that call will be to learn more about you and your goals so that you may be placed in the optimal group.
Finally, we are pleased to announce that Randy Roesch has been brought on as the program facilitator. Roesch has a long track record of vision, dedication, and leadership in PPS. She has had a successful career as a business owner. She brings a wealth of credibility and acumen to the position.
In the summer of 2015, PPS ran a pilot program to refine the Mastermind Group concept. Here are comments from those who participated:
Owning a private practice takes daily diligence, an enormous effort to numerous details, and a ton of personal confidence. Delivering exceptional clinical and operational excellence requires humility toward your peers and vulnerability to the extent that someone else may know a better idea or process. The peer advisory process forces owners beyond their daily norm.”
– Darrin Schober, Owner, Optimum Therapies, Eau Claire, Wisconsin
Having a vehicle to bring together fellow practice owners in a collaborative environment as we did in Washington, D.C., at American Physical Therapy Association (APTA) headquarters was priceless. We each had an opportunity to share our strengths with a group of well-respected peers. I returned from our meeting looking at marketing and operations from a different perspective, and I can say that it had a major impact on my practice and my thought process. It was invigorating, relationship building, and sparked innovative thought. That alone truly created a valuable experience that continues to build on itself. Who would not benefit from the equivalent of a board of advisors to bounce ideas off of?”
– Dan Rootenberg, SPEAR Physical Therapy, New York, New York
The intimacy of the small group setting offered by PPS Masterminds promotes a trusting environment that cannot be achieved with traditional networking. And it is the trust that allows private practice owners, both new and experienced, large and small, to sit down side by side and effectively work on the issues affecting our industry. Within six months of leaving the initial Masterminds meeting, I have implemented five major practice changes that have influenced my clinic’s growth. I cannot imagine not participating in an opportunity like the Masterminds group. It is an unparalleled form of mentorship that is not available elsewhere in physical therapy.”
– Kristen Wilson, Action Potential PT, Glen Mills, Pennsylvania
The peer advisory pilot was an invaluable opportunity to learn from peers in a safe, honest, and dynamic environment. I was challenged to think about many aspects of my practice: management, marketing, professional development, and my own leadership style. I left excited and refreshed with new ideas and a broader understanding of the opportunities that existed to further develop my practice. Finally, I developed trustworthy, genuine relationships with like-minded people that I know will continue to develop and enrich my professional career.”
– Michelle Collie, Performance PT, Providence, RI
Benchmarking Price for Outpatient Physical Therapy Services
By Kelly Sanders, PT, DPT, OCS, ATC
The American Physical Therapy Association (APTA) Private Practice Section (PPS) Payment Policy Committee started what has become known as the Milliman Project to answer a few key questions for PPS members.
These questions include:
- What are physical therapy services really reimbursed at?
- What are the geographic differences?
- What is the difference in price—comparing other alternatives for musculoskeletal pain?
- What is the difference in price—comparing the other services in the continuum of care?
In an effort to answer these questions, the PPS Payment Policy Committee engaged the Milliman Management Consulting Company, an international actuarial and consulting firm, to analyze commercial health insurance and Medicare claims data (excluding workers compensation and Medicaid). Data for physical therapy services, evaluation and management (E&M) codes, chiropractic, radiology, and orthopedic services for price comparisons—and as a point of reference—for bundled payment arrangements for all practices that bill on a Centers for Medicare & Medicaid Services (CMS) 1500 form. Specifically, this data was pulled from 2012 claims and was stratified by geographic region. The data is blinded to payer identity and provides average allowed amounts. Allowed amounts include the total of payer and patient financial responsibility. Also included is per-member, per-month (PMPM) data that is a key metric for payers as it provides a measure of their costs.
In an effort to look not only at physical therapy pricing, but also pricing for alternative interventions to physical therapy, codes evaluated by the Milliman Company included the following code ranges:
- 97001-97762 – Outpatient Therapy Codes
- 27125-27138 – Total Hip Replacement
- 99211-99215 – Evaluation and Management Codes
- 27440-27447 – Total Knee Replacement
- 98940-98942 – Manipulation
- 72148-72149 – Lumbar Magnetic Resonance Imaging (MRI)
In review of alternative treatment interventions, the data suggested that physical therapy was the lower cost option. Specifically, data on chiropractic care suggested not only that physical therapy was more cost effective but also demonstrated better outcomes with less visits and less return patients. Lumbar MRI data supported that using physical therapy as the first treatment intervention for musculo-skeletal injuries could decrease payer costs.
Overall, in review of the data, the Payment Policy Committee came to the following conclusions. First, there was a fair amount of variability on cost to payers by Current Procedural Terminology (CPT) code. Additionally, there was significant variability in the amounts paid to providers based on the geography where services were rendered. Commercial payer average allowable amounts were between the 50th and 75th percentiles and overall were 33 to 50 percent higher than Medicare’s allowable amounts. The allowed amounts in the Milliman data are higher than allowed amounts that private practice physical therapists are receiving. The conclusion we have come to is that hospital and physician practices are receiving higher payments than private practice physical therapists that are skewing those allowed amounts in the data.
A separate observation was that many providers’ billed amounts were close to the Medicare Fee Schedule, thus many were not getting paid the allowed amount by some commercial insurances and thus losing dollars. Based on this observation, the recommendation is that practices evaluate their billed amounts verses the allowed amounts on Explanation of Benefits (EOBs) and consider raising their billed amounts.
What are the take-away points? First, this data in combination with some key data on your practice should assist you in guiding contract negotiation or renegotiation. If you do not already know, review your practice costs to determine what level of payment is needed to sustain your practice and desired profit margins. Once determined, use the Milliman data to review your existing payer contracts as well as to guide you in new contract negotiation. Ask yourself, are the fee schedules in your contracts above your costs by an appropriate margin and how do they relate to the Milliman data for your region and coding? Once reviewed, prioritize which contracts and fee schedules you should consider renegotiating and what payment level you need to be successful. Assess which CPT codes your practice is billing, and consider if carving specific codes out of a contract is a reasonable proposal to your contracted payers. Finally, work to understand the payer’s perspective. What are their costs? Use PMPM data for the CPT codes you are discussing to help determine the payer side.
For detailed information on this topic, the Payment Policy Committee has posted both webinars on the Milliman project. These webinars can be found on the APTA PPS website under the Education tab. Follow the links to “Recorded Webinars” and look for the free webinars titled “What Do We Really Get Paid? Benchmarking Price for Outpatient Physical Therapy Services (April 2015)” and “What Does Everyone Else Get Paid? Benchmarking Price for Outpatient Physical Therapy Alternatives, Part 2 (September 2015).” Additional resources on Payment are also available on the APTA PPS website under the Payment tab in the column on the left side of the screen.
Kelly Sanders, PT, DPT, OCS, ATC, is the president of Movement for Life, Inc., a group of physical therapy clinics operating in California, Arizona, and North Carolina. She is also a member of the American Physical Therapy Association Private Practice Section Payment Policy Committee. She can be reached at email@example.com.
Benchmarking Price for Outpatient Physical Therapy Services
By Alpha Lillstrom
Representative Paul D. Ryan (R-WI) was elected to be the 54th Speaker of the House on October 29 on the retirement of Speaker John Boehner (R-OH). While Speaker Ryan is the youngest to take the gavel since 1869, he has decades of legislative experience having served as legislative staff on the Hill long before he was elected to office. In recent years, he attracted national attention for his sweeping proposals to overhaul Medicare through the use of premium support (through vouchers) and to restructure the tax code. He was also Mitt Romney’s Vice Presidential running mate in the 2012 presidential election.
On becoming Speaker of the House, Ryan resigned as chairman of the House Ways and Means Committee. On November 4, Representative Kevin Brady (R-TX), who had been the chair of the Health Subcommittee, was chosen by the Republican Steering Committee to be the new chair of the full Ways and Means Committee. Brady’s elevation to Chair of the full committee opened up the position on the Ways and Means Health Subcommittee. On November 18, Rep. Pat Tiberi (R-OH) was named the new Chair of the Health Subcommittee. While Tiberi had already been a part of the full committee, he is new to the Health Subcommittee. Representative Erik Paulsen (R-MN) was also tapped to be a member of the Ways and Means Health Subcommittee.
It has been an exciting year for Private Practice Physical Therapy. To prepare for the new Congress that is sworn in this month, the board of directors and the Government Affairs Committee updated the Private Practice Section (PPS) legislative and advocacy priorities. These priorities are being used by the Section’s lobbyists as the guide for PPS advocacy efforts during this 114th Congress, which is now at its midpoint. The priorities that have experienced the most attention and activity are found below in bold.
Permanently replacing the Sustainable Growth Rate (SGR) formula with a reimbursement method that pays physical therapists fairly and predictably, and repealing the arbitrary per beneficiary Therapy Caps on outpatient rehabilitation covered by Medicare are the highest priorities for PPS.
On April 16 of this year, the Sustainable Growth Rate formula was repealed and replaced by the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (Medicare Access and Reauthorization Act of 2015 (MACRA) Public Law. 114-101). PPS actively participated in the broad Medicare payment coalition that was able to achieve this 15-year-old goal. In the same legislation, the therapy cap exceptions process was extended through calendar year 2017. PPS and the Therapy Cap Coalition lobbied vigorously for the inclusion of therapy cap repeal in this must-pass SGR legislation. However, these efforts were unsuccessful.
In an effort to include the provision in the bill, Senators Ben Cardin (D-MD) and David Vitter (R-LA) offered an amendment on the Senate floor to fully eliminate the therapy cap. The PPS grassroots network was activated and physical therapists (PTs) were heard. Fifty-eight senators voted in favor of the amendment. Unfortunately, under Senate rules, 60 votes were required for passage. Had the amendment received 60 votes (and there is good reason to believe that more than two additional senators wanted to vote to repeal but held back for political not policy reasons), therapy cap repeal would have been included in the “doc fix” bill. While clearly disappointed, we are nonetheless gratified to have 58 senators on record in support of permanently repealing this arbitrary and discriminatory beneficiary therapy cap. Several senators, including members of leadership, indicated after this vote that they would work for another opportunity to repeal the provision later in this congressional session. We and the broad Therapy Cap Coalition continue to pursue this legislative goal.
Achieve legislation that allows physical therapists in private practice to optout of Medicare or privately contract with Medicare patients.
The Medicare Patient Empowerment Act (H.R.1650/S.1849), reintroduced by Representative Tom Price (R-GA) and Senator Lisa Murkowski (R-AK), respectively, would modernize the Medicare statute by allowing a Medicare beneficiary to enter into a private contract with an eligible professional (EP)—regardless of whether the EP is a participating or nonparticipating physician or practitioner—for any item or service covered by Medicare. This legislation not only includes physical therapists in the list of eligible professionals, but would also modify existing law to allow for one-to-one billing relationships between a provider and a Medicare beneficiary. Current law only allows for a practice-wide opt-out of Medicare and only for a select list of professionals that does not include physical therapists. This would empower individual beneficiaries by expanding their choices at no additional cost to the Medicare program. Both bills are sponsored exclusively by Republicans; at press time H.R.1650 has 29 cosponsors and S.1849 has four.
Achieve legislation that allows physical therapists in private practice to utilize locum tenens.
This Congress the bipartisan Prevent Interruptions to Physical Therapy Act (H.R.556/S.313) was reintroduced in the House by Representatives Gus Bilirakis (R-FL) and Ben Ray Luján (D-NM) and by Senators Chuck Grassley (R-IA) and Bob Casey (D-PA) in the Senate. PPS lobbyists and members have connected with legislators and shared examples of interrupted Medicare beneficiary care and related challenges faced by private practice physical therapists. These efforts have been effective in attracting considerable support to date. As of November 18, 28 senators have cosponsored the bill and there are 80 cosponsors in the House.
The legislation would add PTs in private practice to the list of health professionals currently authorized by Medicare to enter into locum tenens arrangements with other qualified therapists on a temporary basis in cases such as illness, pregnancy, jury duty, or other short-term absence.
In June the Senate Finance Committee passed a modified version of the bill that would expand the locum tenens provision only to physical therapists working in rural, medically underserved, or health professional shortage areas. This was because the Congressional Budget Office (CBO)—the nonpartisan government entity that determines the cost associated with proposed legislation—had estimated that the nationwide application of the policy would have an impact on the budget. Following this less-than-optimal result, PPS lobbyists worked with Senator Grassley’s staff to challenge the premise CBO used to achieve its cost estimate. We asked the Centers for Medicare & Medicaid Services (CMS) for data and to weigh in on CBO’s assumptions. CMS responded by issuing a letter stating that the Agency “does not have evidence indicating that locum tenens as used by physicians under current law has led to a general increase in utilization of services or that industry practices generally lead to the provision of unnecessary services relating to the use of locum tenens, or that the use of locum tenens under current law in the Medicare program is generally inappropriate, wasteful, or fraudulent.”
In October, the House Energy and Commerce Health Subcommittee convened a hearing on this technical correction. PPS Board member Sandra Norby testified before the panel as to the necessity and the value of locum tenens to private practice physical therapists and their Medicare patients, and her testimony and responses to questions were widely received by the committee members.
As H.R. 556 and its Senate companion bill (S. 313) have both been heard favorably in committee, the next effort will be to get the provision included in a larger piece of relevant legislation (known as a “vehicle”). A measure this small rarely makes it to the floor of either chamber or the president’s desk on its own.
Address and mitigate the negative effects associated with physician self-referral.
The legislative environment of the 114th Congress has not been conducive to addressing this issue. Both chambers are controlled by the Republican party whose members generally oppose restrictions on the practice of physician self-referral. In fact, there are groups of physicians in both the Senate and the House who have openly expressed their resistance. Consequently, no relevant bill has been introduced this Congress.
Encourage and achieve a streamlined, responsive, and transparent process for manual medical review of Medicare records by Medicare administrative contractors.
While Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 MACRA2 did not repeal the therapy cap, it did extend the therapy cap exceptions process through December 31, 2017, and attempted to streamline and reduce the administrative burden associated with manual medical review. Claims exceeding the therapy thresholds are no longer automatically subject to a manual medical review process; instead CMS is permitted to do a more targeted medical review that includes targeting those therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers. Moreover, PPS addressed the issue in its comments submitted on CMS’s proposed rule for the 2016 Medicare Physician Fee Schedule.
Promote the adoption by Accountable Care Organizations (ACOs) of quality measures that include functional health status.
Throughout the year, PPS lobbyists publicized difficulties private practitioners have encountered as a result of the growing presence of ACOs. In addition to raising these concerns in our lobbying efforts on Capitol Hill, strategies for dealing with ACOs were also highlighted in “Advocacy in Action” columns in Impact magazine.
Monitor and respond to ICD-10 implementation in a timely fashion with minimal disruption.
PPS was represented on Capitol Hill in several discussions that focused on the prospects of delaying ICD-10 implementation. Additionally, ICD-10 implementation was the subject of a timely “Advocacy in Action” column in September 2015 Impact magazine.
Achieve legislation that allows reimbursement through Medicare and Federal Health plans for physical therapy care through telehealth.
The Private Practice Section has endorsed the bipartisan Furthering Access to Stroke Telemedicine (FAST) Act of 2015 (H.R.2799/S.1465), which was introduced by Representatives Morgan Griffith (R-VA) and Joyce Beatty (D-OH), and Senator Mark Kirk (R-IL), respectively. Current law does not allow for Medicare reimbursement of telestroke services when the patient originates in an urban or suburban area—where approximately 94 percent of all strokes occur. Under this provision, Medicare would reimburse for the telestroke consultation regardless of the location of the hospital where the patient presents with stroke symptoms. Additionally, the existing originating site facility fee would not apply. The bipartisan H.R.2799 is gaining support quickly, and as of November 18 had garnered 39 cosponsors. The Senate bill still has only one cosponsor, but more activity is anticipated. PPS is among a broad coalition including cardiac and neurology groups who have endorsed this legislation. We are also pursuing opportunities to expand Medicare reimbursement for telehealth to physical therapy.
Continue to fight for fair and equitable Medicare reimbursement for physical therapists in private practice in part by eliminating or mitigating the effects of unsupported multiple procedure payment reduction (MPPR).
Congress enacted legislation that used the MPPR measure to pay for a short-term extension of the SGR physician payment formula in 2013. Since that time, the committees with jurisdiction over Medicare issues have repeatedly refused to revisit the provision. Consequently, it is highly unlikely that the cuts we experienced due to MPPR will ever be restored. The most viable options for returning to a fair method of payment for physical therapy will be through changes to the Current Procedural Terminology (CPT) coding system, the adoption of an alternative payment method, or by sufficient enhancements to the incentive programs associated with the Medicare fee schedule.
Monitor, respond to, and participate in tax reform efforts to benefit physical therapists in private practice.
PPS has endorsed H.R.2712, the Commonsense Reporting and Verification Act (H.R.2712), introduced by Reps. Diane Black (R-TN) and Mike Thompson (D-CA), and the Commonsense Reporting Act (S.1996) introduced by Senators Mark Warner (D-VA) and Rob Portman (R-OH). These bipartisan bills would simplify the Affordable Care Act’s (ACA) reporting requirements affecting employers and insurers. Under these bills, employers can use a voluntary reporting system to provide some data upfront to verify that a plan meets the employer mandate. Backend reporting would only be required for employees who utilize tax credits or cost-sharing subsidies for Exchange (Marketplace) coverage rather than for all workers. The goal of this legislation is to streamline the employer reporting process and strengthen the eligibility-verification process for the health care premium tax credit and cost-sharing subsidy while reducing both employer and employee frustration with the process. These bills are gaining momentum. As of press time, the legislation has five cosponsors in each chamber. PPS is joined by an alliance of employer stakeholders who are also supporting these measures.
Promote policy that increases opportunities for veterans to receive outpatient services provided by physical therapists in private practice.
In 2014, Congress passed the Veteran’s Access, Choice, and Accountability Act3, which includes a provision that allows veterans to receive care from a non–Veterans Administration provider in their community under certain circumstances. In June of 2015, another bill was passed to further improve the law.4 PPS lobbyists have been monitoring the implementation of these laws to identify where regulatory engagement or additional legislation is needed to increase the opportunities for physical therapists in private practice to contract to provide care to veterans.
Pursue improvements in the Physician Quality Reporting System (PQRS) that would result in appropriate participation and recognition of the value of physical therapy.
PPS has suggested improvements to the PQRS in its communications with Congress and CMS. Additionally, in September, PPS submitted comment letters to CMS on two proposed rules: the Medicare Physician Fee Schedule (CMS-1631-P) and a bundled payment initiative known as the Comprehensive Care for Joint Replacement Model (CMS-5516-P). In November PPS responded to CMS’s request for information regarding the new Merit-Based Incentive Payment System (CMS-3321-NC). These letters can be found on the PPS web site www.ppsapta.org.
2016 Medicare Physician Fee Schedule (MPFS) (CMS-1631)
PPS submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its 2016 MPFS Proposed Rule. CMS revised payment policies, updated quality provisions, and has established 2016 payment rates for Medicare-billed services that take place in hospital and ambulatory surgery center settings. During the comment period, PPS shared views and comments with CMS on six topics relevant to our membership. The Final Rule for the 2016 MPFS5 was published on November 16 and will become effective January 1, 2016, for services furnished during that calendar year.
Comprehensive Care for Joint Replacement Model (CMS-5516)
CMS proposed an initiative to support better and more efficient care for beneficiaries undergoing hip and knee replacements (also called lower extremity joint replacements or LEJR). This model, called the Comprehensive Care for Joint Replacement (CCJR) model, would test bundled payment and quality measurement for an episode-of-care associated with hip and knee replacements to encourage hospitals, physicians, and postacute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2013, there were more than 400,000 inpatient primary procedures costing more than $7 billion for hospitalization alone, yet the quality and cost of care for these hip and knee replacement surgeries still varies greatly. In September 2015, PPS filed views and comments with CMS on topics most relevant to the practice of physical therapy in a private practice setting. The final rule was published on November 18, 2015, and the program will be initiated on April 1, 2016.
Centers for Medicare & Medicaid Services Request for Information Regarding Implementation of the Merit- Based Incentive Payment System (CMS–3321–NC)6
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the SGR formula, which had been used to determine updates to Medicare physician fee schedule (PFS) payment rates. MACRA provides for modest (0.5 percent) annual increases in the base fee-for-service (FFS) payments for the next five years. The law also creates the Merit-Based Incentive Payment System (MIPS), which will replace the Physician Quality Reporting System and other quality metrics. Physical therapists will be included in MIPS no earlier than 2021. Additionally, MACRA establishes financial incentives to those eligible professionals (EPs) who participate in Alternative Payment Models (APMs) or who otherwise demonstrate compliance with established quality measures and clinical practice improvement activities. In November, the Secretary of Health and Human Services solicited public comment on an extensive request for information that will set the stage for rulemaking to define the parameters and details of the MIPS program. PPS submitted a lengthy and detailed comment letter that pointed out the numerous provisions necessary to ensure timely and appropriate applicability of the MIPS to PTs in private practice. This comment letter can be found on the PPS website.
PPS Key Contact Program
The Board’s adopted goals are associated with strengthening PPS’ grassroots legislative effectiveness, in part by growing and strengthening the Section’s federal Key Contact program.
Established in 2013, the Key Contact Program has expanded rapidly. The first goal is to have a Key Contact for every Member of Congress in leadership or serving on a committee with jurisdiction over issues that affect private practice physical therapists. These include the Finance and the Health Education Labor and Pensions (HELP) Committees in the Senate, along with the Ways and Means and Energy and Commerce Committees on the other side of the Capitol. Once that benchmark has been met, we will turn our focus toward recruiting for those Members on committees that deal with small business, veterans, workforce, and aging issues. Ultimately, we aspire to have a PPS member assigned to every member of the House and Senate.
We had our first official Key Contact Advocacy Conference in September 2014, and a second in February 2015. Both of these Washington, D.C., based events involved training and preparation of our PPS Key Contacts who then went to Capitol Hill to successfully lobby on our issues. PPS members also joined in the American Physical Therapy Association’s (APTA’s) Hill day in June 2015 to follow up on messages they had previously delivered. Members of Congress responded after each fly-in by cosponsoring legislation that our members asked them to support.
After adding 27 new Key Contacts at the Annual Conference in Orlando, we have 170 PPS members matched with a Member of Congress. Key Contacts have been assigned to 72 percent of Members of Congress in House or Senate Leadership positions. All but three of the Senate Finance and HELP Committees have a Key Contact, and almost 70 percent of the top priority Representatives have a Key Contact. While that is a good start, we are working hard to recruit additional volunteers. Grassroots engagement is the lifeblood of the PPS advocacy program and the Key Contacts are the heart. If you are interested in becoming a Key Contact please contact Cristina Faucheux, the incoming Key Contact Task Force Chair.
Throughout the year, some legislative priorities are thrust into the spotlight. To seize this opportunity, we send targeted Action Alerts that contain context, background, talking points, and contact information to PPS members and/or Key Contacts urging and enabling them to engage in informative outreach to their target legislator. This outreach has been duly noted by Members of Congress and their legislative staff—making lawmakers more aware of how an issue impacts PTs in private practice.
For example, this past March and April 2015, we reached out to PPS members and Key Contacts requesting them to email or call their legislators and ask for them to finally repeal SGR. Key Contacts also asked them to include the therapy cap repeal in that must-pass legislation. In June when it was clear that the Senate was going to mark-up the locum tenens bill in the Finance Committee, we sent out an Action Alert to the Key Contacts of members of that committee. The Senators heard from physical therapists and passed the bill, as amended, out of Finance on a voice vote. As noted previously, the bill is now ready to be voted on by the full Senate.
As recently as September 2015, we sent an Action Alert to those Key Contacts whose assigned Members of Congress were on the House Energy and Commerce Committee because the locum tenens bill was to be discussed in the Health Subcommittee hearing. The Key Contact response was remarkable as many Members who attended the hearing mentioned their experience with, or support for, physical therapy. Still others quoted PTs from their district whose practices were impacted and patient care was interrupted because they were not able to use locum tenens on a short-term basis to provide a qualified therapist when the clinic could not be sufficiently staffed to serve its Medicare patients. These are perfect examples of effective grassroots advocacy.
As we begin the second session of the 114th Congress, PPS legislative priorities will remain intact and our lobbying efforts will build on the progress of this past year. Legislating in the year of a presidential election becomes more difficult but we will continue to work both sides of the Capitol and look for opportunities to advance our legislative agenda. However, we will also have to apply our attention and resources to the numerous regulatory proposals that are increasingly coming our way. On both fronts, PPS grassroots engagement is critical to our efforts.
1. www.gpo.gov/fdsys/pkg/BILLS-114hr2enr/pdf/BILLS-114hr2enr.pdf. Accessed November 2015.
3. Public Law 113-146 signed into law on August 7, 2014.
4. On July 31, 2015, the President signed Public Law 114-41, the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015. Title IV, the VA Budget and Choice Improvement Act made several changes to the Veterans Choice Program.
Alpha Lillstrom is a registered federal lobbyist working with Connolly Strategies & Initiatives, which has been retained by PPS. An attorney by training, she provides guidance to companies, nonprofit organizations, and political campaigns. For six years, she served as Senior Policy Advisor and Counsel for Health, Judiciary, and Education issues for Senator Jon Tester (Montana), advising and contributing to the development of the Affordable Care Act, as well as working on issues of election law, privacy, government transparency, and accountability. Alpha has also directed Voter Protection efforts for Senators Bob Casey, Al Franken, Russ Feingold, and Mark Begich. She was Senator Franken’s Policy Director during his first campaign and was hand-picked to be the Recount Director for his eventual 312-vote win in 2009.