PPS Grassroots Support Boosts Locum Tenens

By Alpha Lillstrom and Jerry Connolly

November 11, 2015

As we are coming up on Annual Conference and we look forward to seeing you all, we are pleased to report on a trio of legislative actions that represent various tenets of the Private Practice Section’s advocacy agenda.

Progress on Locum Tenens
As you know, this year Senators Charles Grassley (R-IA) and Robert Casey (D-PA) as well as Representatives Gus Bilirakis (R-FL) and Ben Ray Luján (D-NM) reintroduced the Prevent Interruptions to Therapy Act of 2015 (H.R.556/S.313) to authorize physical therapists to use the existing locum tenens provision of the Medicare statute so that the practice could bill and be reimbursed for treatment provided by a qualified provider when the practice owner is absent for a short time. In addition to easing the administrative burden on practice owners, including physical therapists in this provision would, more importantly, help to ensure that Medicare patients could continue their care without interruption. Simply put, this bill is a low-cost technical fix that would add physical therapists to the list of providers allowed to utilize locum tenens arrangements under Medicare (when all other conditions are met and within their same authorized scope of practice).

As we reported in June, the Senate Finance Committee passed a modified version of this measure that limited the bill’s application to physical therapists practicing in Health Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs) and rural areas (defined as non-Metropolitan Statistical Areas (non-MSA) areas. While passage of the bill by the powerful Senate Finance Committee was an important benchmark, we objected to, and were disappointed with, the restriction. The need for locum tenens is driven more by practice size than practice location. Consequently, we have remained focused on the legislation as introduced that applies to all private practice physical therapists nationwide. At its core, locum tenens in physical therapy is a beneficiary issue—facilitating the continuity of care of the Medicare patient when the practice owner needs to be away from the clinic.

Over in the House, the Energy & Commerce Health Subcommittee included H.R.556 in a hearing, “Examining Potential Ways to Improve the Medicare Program,” which took place on October 1. During that hearing, Private Practice Section (PPS) board member Sandra Norby, PT, AT, (Iowa) testified before the subcommittee citing the need for and importance of passing HR 556. Ms. Norby provided a 5-minute oral testimony (available at ppsapta.org) and then deftly responded to numerous questions from more than ten members of the subcommittee, including Chairman Joe Pitts (R-PA) and bill sponsors Bilirakis and Lujan.

To quell concerns raised about potential for fraud and abuse if the bill were to be enacted, Norby quoted a letter her senior senator, Charles Grassley (R-IA), received from the Centers for Medicare and Medicaid Services 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.

Norby also emphasized that HR 556 is “a simple technical fix” that updates a 40-year-old law and is primarily a Medicare beneficiary issue, pointing out that when an elderly patient’s care is interrupted unnecessarily, the likely resultant regression in function is not only counterproductive, but can be harmful. Moreover, she testified, this can and does result in the need for more care which in turn is more costly to the Medicare program.

With the help of PPS grassroots, this legislation has garnered considerable support. As of October 1, 27 senators have cosponsored the bill and there are 78 cosponsors in the House. In fact, during the October 1 hearing, it was evident that members of the PPS grassroots had effectively connected with their representative, as legislator after legislator remarked about having heard from their constituents and many even provided specific examples of how the lack of locum tenens in physical therapy has caused needless problems for Medicare patients and the private practice where they have chosen to receive their physical therapy.

Now that H.R. 556 and S. 313 have both been heard favorably in committee, the next effort will be to get the provision included in a larger Medicare bill as a measure this small rarely makes it to the floor of either chamber or the president’s desk on its own. The PPS grassroots will be instrumental for that strategy as well; we hope you all will once again respond quickly and effectively to our legislative alerts.

Other PPS-Endorsed Legislation
And now on to two bills the Section has endorsed as they are consistent and compatible with the Board-adopted PPS 2015 Legislative and Advocacy Priorities; specifically with the following goals:

• Achieve legislation that allows reimbursement through Medicare and federal health plans for physical therapy care through telehealth;
• Monitor, respond to, and participate in tax reform efforts to benefit physical therapists in private practice.

In June 2015, the Government Affairs Committee (GAC) recommended to the PPS Board of Directors that PPS endorse the Furthering Access to Stroke Telemedicine (FAST) Act of 2015 (H.R.2799/S.1465) as well as the Commonsense Reporting and Verification Act (H.R.2712), and the Commonsense Reporting Act (S.1996). On July 14th, the Board approved the GAC’s recommendations and the Section endorsed these measures and sent the appropriate communications to Congress.

Telehealth
State telehealth laws vary widely. While 27 states have enacted legislation requiring parity in private insurance payment for telehealth services, only 16 states and the District of Columbia authorize statewide coverage without any provider or technology restrictions. As of this writing, telemedicine parity bills are being considered in an additional 8 states: Connecticut, Delaware, Illinois, Massachusetts, New Jersey, North Carolina, Ohio, and Pennsylvania.

Of the 48 states that have mandated Medicaid coverage of telemedicine, only half did not specify a type of patient setting as a condition for payment. Twenty-five states recognized the home as an originating site for virtual visits.

As we all know, time is of the essence in treating stroke. “Telestroke”—the use of telemedicine in the treatment of stroke—has proven highly effective in improving patient access to quality stroke care. However, barriers such as lengthy travel times to primary stroke centers can delay treatment that can increase survivability, prevent long-term disability, and foster conditions for the patient to achieve a much higher functional outcome.

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. The FAST Act would provide Medicare beneficiaries who reside in these areas access to important immediate care via telemedicine.

Medicare continues to lag behind the states in reimbursement for care delivered via telehealth, so Representatives Morgan Griffith (R-VA) and Joyce Beatty (D-OH) introduced the bill in the House, and Senator Mark Kirk (R-IL) is the chief sponsor in the upper chamber. Under this provision, Medicare would expand access to stroke telehealth services under Medicare by covering evaluation or intervention of an acute stroke provided within the evidence-based timeframe, covering any site where this originating treatment takes place; and waiving any originating site facility fee for locations where this evaluation or treatment takes place. This provision is based on Section 105(a)(1) of the Telehealth Enhancement Act (H.R.3306 and S.2662 in the 113th Congress).

By October 1, the bipartisan H.R.2799 had garnered 28 cosponsors (14 from each party). The Senate bill still had only one cosponsor, but more activity is anticipated. PPS is among a broad coalition including cardiac and neurology groups supporting this legislation.

Tax Reform Measures
Under the Affordable Care Act (ACA), employers must track monthly and report annually to the Internal Revenue Service (IRS) which of their workers receive employer-sponsored health insurance. This reporting to the IRS includes the personal information of every covered person, including the birthdates and Social Security numbers of workers’ children. These data are used to verify compliance with the individual and employer mandates under the law, as well as to administer premium tax credits for health coverage in Exchanges (aka insurance marketplaces). The ACA does not allow workers or their families to receive federal subsidies if their employers offer affordable coverage that meets the minimum essential coverage requirements in the law. Consequently, under the current system, workers who choose to purchase through an Exchange instead of using their qualifying employer coverage may mistakenly receive subsidies to which they are not entitled. If this occurs, such employees would be required to pay back the money when they file their taxes. This worker frustration could easily translate to dissatisfaction with the employer.

The bipartisan Commonsense Reporting and Verification Act (H.R.2712), introduced by Representatives 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), would reform the ACA’s reporting requirements affecting employers and insurers. Under this legislation, compliance with the individual and employer mandates would be completed through a voluntary reporting system in which employers can verify up-front that a plan meets the employer mandate. Back-end reporting would only be required for employees who utilize tax credits or cost-sharing subsidies when purchasing coverage through the Exchange. This legislation aims to streamline the employer reporting process and strengthen the eligibility verification process for the health care premium tax credit and cost-sharing subsidy while simultaneously reducing both employer and employee frustration with the process. The bills differ slightly because of the amount of technical assistance their sponsors utilized from the Department of Treasury.

The legislation has four primary provisions.

1. It creates a voluntary prospective reporting system, allowing employers to report general information about their health plan for the current plan year to the IRS (increasing the accuracy of eligibility determinations for Exchange tax credits). Exchanges will access information securely through the Data Services Hub;
2. It streamlines the reporting process and eases the reporting burden for employers by requiring data only for those employees or their dependents who received subsidies (rather than for the entire workforce);
3. It protects privacy by eliminating the requirement that employers and insurers collect and remit dependents’ and spouses’ Social Security numbers; and
4. It modernizes transmission of information to individuals by allowing electronic transmission of employee and enrollee statements.

While it is recognized that few PPS members have businesses that meet the employer mandate threshold of 50 full-time equivalent (FTE) employees, PPS endorsed this legislation because it provides commonsense, small business–friendly reforms to the tax code.

As of this writing, the above-referenced bills are slowly gaining momentum. H.R.2712 now has 3 cosponsors (2 Republicans, 1 Democrat). The Senate bill also has 3 cosponsors (1 Republican, 2 Democrats). In addition to PPS, an alliance of employer stakeholders supports these bills. 

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.

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.