APTA delivered a set of comments on the US Centers for Medicare and Medicaid Services' (CMS) proposed 2019 physician fee schedule that were as wide-ranging as the proposal itself, including qualifications on the proposal to extend the Merit-based Incentive Payment System (MIPS) to physical therapists (PT) and clear opposition to a CMS move to lower payment for services provided "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). Also in the association's comments: recommendations that CMS could strengthen its role in the fight against opioid abuse by better supporting nonpharmacological approaches to pain management, including physical therapy, through payment and education improvements.

The extensive comments were developed in response to a rule that, if implemented, would include some of the most far-reaching changes in payment and reporting to date, moving PTs into the Quality Payment Program (QPP) and ending functional limitation reporting (FLR) requirements. But that's just 1 facet of the proposal: the rule touches on everything from the use of telehealth to additional current procedural terminology (CPT) codes. APTA's comments addressed both big-picture issues and some of the nuts-and-bolts of the proposal.

PTs in MIPS: a move that needs to be carefully implemented.
APTA provided extensive comments to CMS on its proposal to include PTs in QPP—and more specifically in MIPS—characterizing the change as an acknowledgement that PTs "act as integral members of the health care delivery team in outpatient settings."

APTA's comments outlined a number of concerns and issues, mostly centered on the association's concern that PTs could face serious barriers to participation in MIPS unless CMS provides "certain amnesties." The association also recommends that CMS adopt more flexible approaches when it comes to PTs opting in to MIPS participation, as well as the measures CMS would accept should facility-based PTs be required to participate in MIPS in the future (the current proposed rule only includes PTs in private practice settings).

APTA also went on record to support a proposed "Physical and Occupational Therapy Specialty Measure Set" within MIPS, and the continued efforts by CMS to eliminate measures that are "topped-out" through high levels of compliance.

CMS has it all wrong when it comes to adjusting payment for services provided "in part" by a PTA.
Some of the association's strongest criticism of the proposed rule is aimed at CMS efforts to establish payment differentials, set to go into effect in 2022, based on the extent of a PTA's or OTA’s role in a visit. That criticism is centered on what APTA believes is the impossibility of accurately defining when a PTA or OTA has sufficiently provided services "in part" to trigger a payment differential, and the dangers of creating a rule stating that any PTA involvement constitutes an excuse for lower payment rates.

While APTA acknowledges that CMS is bound by law to establish a PTA modifier, the association asserts that CMS isn't obligated to go down the definitional rabbit hole associated with pinning down what constitutes care delivered "in whole or in part" by a PTA. In its comments, the association lays out a multipoint case against establishing rules based on terminology that isn't a term of art or statutorily defined, warning that drawing a line on what constitutes "in part" could quickly lead to confusion and loss of access to care, particularly among beneficiaries in rural areas.

APTA recommends that CMS take more time to reexamine the potential problems and wait until next year's rulemaking to address the "in part" issue. Alternatively, should CMS insist on moving ahead in this rule, the association suggests either of 2 more-straightforward approaches: the so-called "midpoint rule" that would pin 100% reimbursement to whether the majority of services are furnished by the PT; or a "blended rate" approach that splits the fee schedule amount for a code in half and then applies the 100% PT rate to one half, and an 85% rate to the other half, thereby avoiding a single trigger that would shift payment to a lower rate, simply because a PTA provided care "in part."

Should CMS continue down the PTA payment differential path, APTA strongly recommends CMS exempt rural areas, health professional shortage areas, and medically underserved areas from the proposed policy, due to concerns of how it could affect patient access. Earlier this summer, CMS indicated to APTA and the American Occupational Therapy Association (AOTA) that it did not have the statutory authority to exempt these areas. APTA is investigating whether that's true, and APTA and AOTA also are advocating for Congress to commission a US Government Accountability Office study to examine how access to physical therapy and occupational therapy will be impacted by the payment differential.

"Given that a [PT] and PTA frequently deliver team-based care, we have serious concerns that requiring the modifier to be applied if any minute of outpatient therapy is delivered by the PTA has serious implications for beneficiary access to care," APTA writes. "Physical therapists and PTAs serve a critical role in the health and vitality of this nation. It is imperative that Medicare beneficiaries continue to have access to high-quality physical therapy services."

More can be done to fight the opioid crisis if CMS would provide stronger support of (and better payment for) nonpharmacological approaches to pain management.
APTA recommends that CMS not only step up its promotion of access to team-based nondrug pain management, but that it back up this support with "subregulatory revisions" that could increase patient access through changed payment models. The association also recommends that CMS reduce or eliminate copays for nonpharmacological pain treatments, and that the agency increase efforts to educate both prescribers and the public on the effectiveness and availability of approaches to pain that don't involve the use of opioids.

Additionally, APTA has a suggestion for providers who continue to prescribe opioids for pain: make a referral to physical therapy a requirement.

"CMS and other stakeholders must ensure that not only is education for providers enhanced, but that a clear, direct path exists for patients in pain to access all treatment options, including physical therapy," APTA writes. "Given that [the US Centers for Disease Control and Prevention] has concluded that there is insufficient evidence that opioid usage alone improve functional outcomes for those in pain, we recommend that clinicians who prescribe an opioid for pain also must be required to refer a patient to physical therapy."

Other provisions in the proposed rule didn't escape APTA's notice.
As is usually the case, the proposed fee schedule covered a lot of regulatory ground. APTA took an equally comprehensive approach in its comments, touching on these additional areas:

• Barriers to PTs participating in alternative payment models (APMs). While PTs technically are allowed to participate in APMs, APTA argues that from a practical standpoint, the profession is at a disadvantage thanks to barriers thrown up by CMS around the use of certified electronic health record technology (CEHRT). CMS requires at least 75% of all eligible clinicians to use CEHRT—the problem is, PTs have been exempt from "meaningful use" criteria promoting interoperability, and there is a lack of physical therapy-specific CEHRT. The result? "[PTs] are essentially barred from participating in advanced APMs," APTA writes. The association is also advocating to Congress to require CMS to develop physical therapy-specific certification criteria for electronic health record vendors.
• Payment for technology-based communications. APTA supports CMS efforts to provide payment for physician communications provided via technology and has asked CMS to clarify whether PTs are included in the list of eligible providers. If not, APTA says, CMS should study that possibility and consider expanding provisions in the fut
• Qualified Clinical Data Registry (QCDR) proposals. Because QCDRs such as APTA's Physical Therapy Outcomes Registry could play such an important role in future value-based care models, the association is paying particular attention to CMS proposals for who gets to be included as a QCDR, and the nature of the relationship between a QCDR and CMS. Specifically, APTA supports a CMS plan to require a QCDR entity to have clinical expertise in medicine and measure development, and it backs the measures selection criteria proposed by CMS. However, the association isn't on board with a CMS proposal that beginning in the 2021 payment year, all approved QCDRs must enter into a licensing agreement with CMS that would allow any QCDR to report on any MIPS measure.
• Price transparency. In response to a CMS request for perspectives on price transparency, APTA stated its general support for greater transparency but recommended that CMS study state-level initiatives first. The association also cautioned CMS to be careful about how it defines "cost" from a consumer perspective and to avoid divorcing issues of cost from concepts of quality. Additionally, APTA recommended that any price transparency effort be accompanied by extensive public education efforts.