Physical therapy on Capitol Hill.
By Jerome Connolly, PT, CAE
April 4, 2015
The Private Practice Section (PPS) conducted its third successful Capitol Hill Lobby Day this past February. This year, our forces were fortified thanks to collaboration with the American Physical Therapy Association (APTA), which brought 25 additional physical therapists to Washington, D.C. Members of the APTA’s board of directors and the Payment Policy Advisory Committee joined the 72 PPS Key Contacts in walking the halls of Congress, conducting 185 meetings discussing the Medicare beneficiary therapy cap, payment rate, and locum tenens. Forty states and 105 unique House districts were covered by the total 97 attendees, many of whom met with their actual representative or senator.
The timing for this meeting, which was optimal, was established by the PPS board of directors and was heavily influenced by the looming March 31 deadline when the therapy cap would be fully implemented and Medicare reimbursement for outpatient services would be cut by more than 20 percent. The payment reduction is due to the expiration of the waiver of the sustainable growth rate (SGR) used to calculate the conversion factor for the Medicare physician fee schedule under which outpatient physical therapy services are paid.
PPS to Lobby Congress in February.
By Jerome Connolly, PT, CAE
February 2, 2015
As we learned in January, due largely to members engaging in advocacy efforts, the Private Practice Section (PPS) reported substantial progress on its federal legislative and advocacy priorities in the 113th Congress. Significant steps were taken with respect to the Sustainable Growth Rate (SGR), the formula used to determine Medicare reimbursement rates. We also prevented the Medicare therapy caps from being fully imposed on our patients. We introduced bills in both chambers that would add physical therapists to the Medicare Locum Tenens statutory provision that allows physicians and other health professionals to retain qualified licensed professionals in their practices when the owner needs to be absent for a short time due to illness, pregnancy, professional development, or jury duty. Physical therapists were included in the Medicare Patient Empowerment Act (HR 1700), which represented an important step in identifying the physical therapy profession with the opt-out issue when such legislation is revisited in the next Congress. Even on the polarizing issue of physician self-referral, steps forward were made with the new bill (HR 2914) that would close the in-office ancillary services exception loophole.
But with the opening of the 114th Congress, all legislation must begin anew and steps are underway to line up sponsors and supporters for legislation consistent with PPS advocacy goals.
The new Congress was seated in early January but little legislation is typically accomplished in the first 90 days. New members need to receive committee assignments, orientation, and an opportunity to familiarize themselves with their colleagues, hire staff, and organize their offices. In addition, two weeks is spent back home in their district connecting with constituents. Congress also returns to their constituents in February during a weeklong break recognizing the birthdays of presidents George Washington and Abraham Lincoln.
All this suggests a compressed timetable for the first 60 to 90 days, one not so compatible with accomplishing substantive policy work on Medicare payment. This timing is unfortunate as the current Medicare payment rate and the extension of the exceptions process for the Medicare beneficiary therapy caps expire March 31.
In the last Congress, substantial progress was made in creating legislative policy that would repeal and replace the SGR formula and repeal and replace the therapy caps. However, since such legislation was developed under different leadership in the Senate and in different leadership of key committees in both the Senate and the House, it is unlikely that policy will be advanced under the new regime.
A Republican majority now rules the Senate and Senator Orrin Hatch (R-UT) holds the gavel for the quite influential Senate Finance Committee. Chairman Hatch believes the future of Medicare is at risk, calling it the single greatest contributor to our nation’s debt. Says Hatch, “If we are to tackle our runaway debt, then Medicare must be on the table.” He strongly supports efforts to modernize and reform the Medicare program using more, not less, patient empowerment and greater choice for seniors. Hatch is also a strong supporter of the Medicare Advantage (MA) program, which he says represents a strong foundation for addressing Medicare’s long-term fiscal challenges.1
Over in the House, Representative Paul Ryan (R-WI) assumes chairmanship of the powerful Ways and Means Committee. Ryan, the 2012 GOP vice presidential nominee, has proposed Medicare reform on at least two occasions by employing what he referred to as premium support. Under this policy, Medicare beneficiaries would receive insurance vouchers that could be used as payment toward Medicare coverage, which would be a choice between traditional fee-for-service Medicare or a list of private health plans.2
Ryan emphasizes that his proposal still gives seniors the choice of remaining in regular Medicare.3 However, a Congressional Budget Office (CBO) analysis of Medicare premium support systems found that plans such as Ryan’s would increase traditional Medicare premiums by a staggering 50 percent.4
Ryan’s proposal would establish an exchange for private Medicare insurance plans. Health plans that chose to participate in the Medicare Exchange would agree to offer insurance to all Medicare beneficiaries, to avoid cherry-picking, and to ensure that Medicare’s sickest and highest-cost beneficiaries receive coverage.
A third House committee, Energy and Commerce, with jurisdiction over some Medicare policy will retain its current chairman in the person of Representative Fred Upton (R-MI). Upton is in concert with the proposals espoused by Hatch and Ryan as is evidenced by a policy document recently released by the committee calling for combined Medicare Part A and Part B fee-for-service deductibles, means testing, and the strengthening of Medicare advantage.5
As chairs of these committees with jurisdiction over Medicare, and a track record of proposing bold policy changes to the program, chairmen Hatch, Ryan, and Upton will be eager to craft Medicare reform (including payment reform) to their likeness.
Reform of the SGR and the therapy caps has been considered by Congress since 2001, and both issues have enjoyed bipartisan support. But the parties have disagreed over how to pay for such revisions to the Medicare law. Now that Republicans control both the Senate and the House, methods of funding the Medicare legislation should be easier to identify. The only obstacles will be skirting the filibuster in the Senate and making the policy sufficiently palatable to President Obama as his signature will be required. While it is possible to avoid the filibuster by employing a parliamentary tactic known as “Budget Reconciliation,” getting Obama to sign a bill that guts or seriously threatens the Affordable Care Act, his signature legislation, will be much more difficult.6
It is highly unlikely that these two new chairmen can successfully undertake the scale of Medicare reform they both envision by the above-mentioned March 31 deadline. Failure to accomplish such reform would hopefully compel the Congress to entertain yet another short-term patch to the Medicare payment formula. Failing to do so will result in a 20.4 percent reduction in Medicare reimbursement rates to therapists and physicians on April 1 (and that’s no April Fool’s joke).
Likewise, the therapy caps exceptions process also expires March 31, and would require an extension to avoid the full provisions of the cap being applied to all Medicare patients. Therapy cap legislation traditionally is included in Medicare SGR bills, but this is no given. In fact, we would be foolish to believe that even the avoidance of the steep Medicare payment rate cut is assured at this time. The new Congress, with new committee chairs and a vastly more complex political climate in Washington, creates a much more volatile legislative environment in which nothing should be taken for granted.
For this reason, PPS will convene its third “Lobby Day” in as many years this month. The Section will bring its Congressional Key Contacts to Washington to lobby our legislators and policymakers on these important Medicare issues. This fly-in, to be conducted February 22-24, presents an important opportunity for PPS to make an impression and create a presence with the members of the 114th Congress.
We hope nearly 100 PPS members answer this call to come to Washington to learn about the issues from members of Congress and their staff, become adept at presenting our “asks,” and persuading our legislators to take the appropriate action with respect to Medicare policy affecting our patients and our practices.
In addition to the critical issues of SGR and therapy caps, we will be advancing our other advocacy priorities developed by the PPS Government Affairs Committee and adopted by the Board of Directors, including locum tenens, opt-out, and physician self-referral. (See sidebar on page 26.)
The PPS advocacy program could not have made the progress recorded last year without the willing and eager participation of its grassroots members. The PPS Key Contact program is growing as we identify more members willing to serve the Section in this capacity. Creating relationships with your federal legislators, both at home and in Washington, is of critical assistance in advancing the PPS advocacy goals. If you have not yet registered and made plans to attend the February PPS Lobby Day, I would encourage you to promptly do so. Your patients and your profession are counting on you.
PPS Legislative and Advocacy Priorities for 2015
Permanently replacing the Medicare Sustainable Growth Rate 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.
Other Medicare Priorities
- Achieve legislation that allows physical therapists in private practice to opt out of Medicare or privately contract with Medicare patients
- Achieve legislation that allows physical therapists in private practice to utilize locum tenens
- Pursue elimination of arbitrary limits and denials for services provided by physical therapists in private practice in accordance with evidence of value
- Address and mitigate the negative effects associated with physician self-referral
- Encourage and achieve a streamlined, responsive and transparent process for manual medical review of Medicare records by Medicare administrative contractors
- Promote the adoption by the Accountable Care Organizations (ACO) of quality measures that include functional health status
- Remove the barriers to patient access to physical therapists in private practice under Medicare and the Federal Employee Health Benefit Plans
- Achieve consistent Medicare standards for supervision of support personnel across physical therapy practice settings
- Promote policy that embraces the use of physical therapists in private practice as timely evaluators and managers of quality of life for patients with chronic conditions
- Monitor and respond to ICD-10 implementation in a timely fashion with minimum disruption
- Achieve legislation that allows reimbursement through Medicare and federal health plans for physical therapy care through telehealth
- 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)
- Pursue improvements in the Physician Quality Reporting System (PQRS) that would result in appropriate participation and recognition of the value of physical therapy
- Support opportunities for physical therapists in private practice to purchase health insurance across state lines
- Address and mitigate the negative effects of market control by insurance plans and related entities on physical therapists in private practice and their patients
Small Business Issues
- Pursue federal student loan repayment programs in underserved areas that enhance recruitment efforts of physical therapy private practices in these areas
- Monitor, respond to, and participate in tax reform efforts to benefit physical therapists in private practice
Other Federal Issues
- Promote policy that increases opportunities for veterans to receive outpatient services provided by physical therapists in private practice
- Mandate that physical therapists in private practice are included in the medical team providing concussion management
1. Hatch website (accessed 12/29/14): www.hatch.senate.gov/public/index.cfm/releases?ID=88a3acbc-7608-4bde-aaf3-2d568e9ba3a5.
2. Paul Ryan’s budget makes big Medicare changes, Politico, April 1, 2014.
4. A Premium Support System for Medicare: Analysis of Illustrative Options, Congressional Budget Office, September 2013, http://www.cbo.gov/sites/default/files/cbofiles/attachments/09-18-PremiumSupport.pdf.
5. GOP Solutions: A Compilation of Policy Proposals from the House Committee on Energy and Commerce, Dec. 29, 2014. http://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/files/The%20Policy%20Paper%20Series%20—%20V3I3%20Compilation.pdf.
6. Policy Basics: Introduction to the Federal Budget Process, Center on Budget and Policy Priorities, 9/10/14, www.cbpp.org/cms/?fa=view&id=155.
Jerome Connolly, PT, CAE, is a registered federal lobbyist whose firm, Connolly Strategies & Initiatives, has been retained by PPS. A physical therapist by training, he is a former private practitioner who throughout his career has served in leadership roles of PPS and APTA. Connolly also served as APTA’s Senior Vice President for Health Policy from 1995–2001.