A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

"We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

"Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

"Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

"A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."