Statement of the American Physical Therapy Association, Alexandria, Virginia

The American Physical Therapy Association (APTA) appreciates the efforts of the House Committee on Ways and Means and its Subcommittee on Health to improve the delivery of health care, especially your focus on quality care for seniors and persons with disabilities.   The transition to a payment system for high quality, efficient health care services is vitally important to the beneficiaries that physical therapists serve under the Medicare program.  APTA endorses and supports HR 3617, the Medicare Value-Based Purchasing for Physicians’ Services Act of 2005.  While we support HR 3617, we encourage the Committee to address all of the inadequacies in the current payment system in conjunction with its action on this legislation.

Elimination of the Flawed Sustainable Growth Rate (SGR) Methodology Prior to Moving Forward with Value-Based Purchasing for Health Professionals’ Services: 

HR 3617 eliminates the flaws of the existing system that determines Medicare payments to physical therapists and other providers under the Part B physician fee schedule, as well as improving the program’s long-term solvency by creating incentives to improve the quality of care provided to the nation’s seniors and persons with disabilities.  We are concerned that any effort to proceed with the transition to value-based purchasing or “pay for performance” without also addressing underlying flaws in the outpatient payment of physical therapy services would be inefficient and would ultimately erode the purpose of this legislation.  By repealing the Sustainable Growth Rate (SGR) and replacing it with the Medicare Economic Index (MEI), the MedicareValue-Based Purchasing for Physicians’ Services Act of 2005 (HR 3617) resolves one of the current payment inadequacies under Medicare Part B, and APTA commends Chairwoman Johnson and the Committee for addressing this critical payment issue.

Therapy Caps’ Inconsistency with Value-Based Purchasing for Physical Therapists’ Services under Medicare:

The pending restoration of financial caps on outpatient physical therapy services under Medicare threatens to limit this legislation’s ability to fully achieve its objective.   Congress must address the arbitrary caps placed on outpatient physical therapy services by the Balanced Budget Act of 1997 prior to transitioning to a valued-based system.   If the therapy caps are not repealed, the effect of HR 3617 would be the application of two different payment systems to rehabilitation services at the same time:  one system that pays for quality, efficiency, and improved outcomes in clinical practice implemented on top of another that arbitrarily caps beneficiary coverage that is based upon the former paradigm of volume and utilization.  The implementation of an arbitrary financial limit is inconsistent with the goals represented by a value-based purchasing system.  The objective of HR 3617 is the transition to a payment system that rewards quality, outcomes, and efficiency in clinical practice; arbitrary caps on services undermine and erode this objective.  APTA stands ready to work with you and your Committee to address the therapy caps and incorporate value-based purchasing into the solution for this issue.

Inclusion of Non-Physician Providers in the Medicare Value-Based Purchasing for Physicians’ Services Act of 2005 (HR 3617):

It is our understanding that your legislation is intended to include physical therapists practicing in outpatient settings, but we would encourage you to specifically reference physical therapists as participants in the development and attainment of clinically appropriate processes and measures to enhance the quality of rehabilitation care.  We strongly encourage the inclusion of non-physician providers in the value-based purchasing discussions conducted by this committee and CMS.   In the 2006 Medicare Physician Fee Schedule proposed rule, CMS discusses its current involvement with the physician community in developing useful quality measures and understanding overall trends. Although we are pleased to see that CMS is willing to work collaboratively with physicians to develop quality measures, we strongly urge CMS and this committee to also include physical therapists and other non-physician groups in these discussions.  There are more than 120,000 physical therapists in the United States, many of whom provide services to Medicare beneficiaries and would be able to provide useful information regarding appropriate quality measures for physical therapy services. CMS has indicated that 3,747,395 Medicare beneficiaries (9.3%) accessed outpatient therapy services in CY 2002, resulting in expenditures of $3,392,226,958 for the Medicare program, which accounts for 2.3% of all Medicare Part B expenditures during that year.  Although the annual per-patient expenditure for PT services is only $760, 88% of the recipients of Medicare-covered rehabilitation receive physical therapy specifically, totaling $2.54 billion and accounting for 75% of the total costs of all outpatient rehabilitation services combined.  These numbers clearly indicate that physical therapy is an essential outpatient benefit that should be incorporated into any transition to value-based purchasing for physicians and other health care professionals.

 Standardization of a Consistent and Uniform Benefit for Physical Therapist Services in All Part B Settings:

APTA believes that the fragmentation of rules and regulations across the multiple settings in which physical therapists provide services to Medicare beneficiaries creates serious problems for a uniform and consistent value-based purchasing payment system.  Currently, physical therapists provide outpatient services in eight (8) Part B settings, each governed by different requirements regarding supervision, certification of plans of care, and billing authority.   APTA believes that value-based purchasing would be enhanced and provider accountability increased by moving physical therapy to a uniform part B benefit similar to the physical therapist in private practice (PTPP) benefit, which improves accountability with individual provider numbers for each licensed physical therapist, similar to physician providers.   We would welcome the opportunity to simplify the Part B physical therapy benefit by eliminating the fragmentation of physical therapy services across all Part B settings.

APTA’s Efforts to Support Value-Based Purchasing for Physical Therapists Services:  A Foundation for Pay for Performance in Therapy Services:

APTA believes that physical therapist practice is congruent with this initiative due to its focus on measurable outcomes of function, movement, and activities of daily living.  We support reforming the Medicare payment system to reward providers for meeting clinically appropriate benchmarksto promote quality and improve the health outcomes of the Medicare population.  APTA has been actively engaged in several initiatives to expand the utilization of health information technology and outcome measures that would lead to quality improvements in the provision of physical therapy services as well as to an effective value-based purchasing system for this essential service to Medicare beneficiaries.  

To achieve these objectives, APTA has developed a specialized point-of-care electronic patient record system (CONNECT) designed for use by physical therapists, and a patient self-report instrument, the Outpatient Physical Therapy Improvement in Movement and Assessment Log (OPTIMAL) which documents the outcomes of physical therapist treatment.  Specifically, OPTIMAL provides an outcome measure of the patient’s functional status related to changes in movement. The patient uses OPTIMAL at the initiation of treatment and at discharge to indicate the level of difficulty experienced in performing 21 actions (e.g. rolling over, sitting, standing, bending, reaching, etc.) and the level of self-confidence in the ability to perform them.  We firmly believe that OPTIMAL will be a valuable instrument in a pay-for-performance system.    CONNECT enables practices to document the performance of a physical therapist in a particular practice and benchmark that performance with other clinicians.  APTA would be happy to share the data derived from CONNECT with CMS so that it may be used to develop quality measures for a pay-for-performance system.  APTA’s ultimate objective is to develop a national outcomes database that will enable the profession to determine the effectiveness of physical therapist practice and to provide quality measures to assist payers such as Medicare shift to payment systems that reward quality.  We believe our efforts are consistent with the objectives that your legislation outlines and should assist the Centers for Medicare and Medicaid Services (CMS) in developing and implementing quality measures for physical therapists of the kind envisioned by your legislation.

Recognizing the need for evidence-based practice, APTA also initiated a project several years ago referred to as “Hooked on Evidence,” which involved the creation of a website dedicated to literature review on physical therapy efficacy.  Specifically, APTA’s Hooked on Evidence Website consists of a database of current evidence on the effectiveness of physical therapy interventions drawn from scientific research literature. The website allows physical therapists to search a database of extractions from peer-reviewed literature relevant to physical therapy, which has been aggregated to produce research-based guidelines for clinical practice.

APTA has also developed the Guide to Physical Therapist Practice (“the Guide”), which helps physical therapists analyze their patient/client management and describe the scope of their practice.  The Guide delineates tests and measures and the interventions that are used in physical therapist practice.  It also identifies preferred practice patterns that will help physical therapists (a) improve quality of care, (b) enhance positive outcomes of physical therapist services, c) enhance patient/client satisfaction, (d) promote appropriate utilization of health care services, e) increase efficiency and reduce unwarranted variation in the provision of services, and f) diminish the economic burden of disablement through prevention and the promotion of health, wellness, and fitness.  Through the development of a health information technology infrastructure that supports quality improvement by providing physical therapists with tools to support evidence-based clinical decision making and incorporate performance measurement in their practices, APTA is helping to lay the groundwork for Medicare pay–for-performance.

Conclusion:

In summary, we recommend the following principles to enhance the H.R. 3617, the Medicare Value-Based Purchasing for Physicians’ Services Act of 2005:

• Maintain the repeal of the Substantial Growth Rate (SGR) and its replacement with the Medicare Economic Index (MEI) in HR 3617.
• Eliminate the arbitrary therapy caps for physical therapists, occupational therapists, and speech language pathologists. If value-based purchasing rewards high quality, efficient, and clinically appropriate care, implementation of the therapy caps would unnecessarily limit essential benefits for our seniors and persons with disabilities, and would ultimately lead to increased costs in other areas.
• Include non-physician providers explicitly as part of value-based purchasing under Medicare.  Physical therapists are paid according to the same fee schedule as physician providers and should be included in this new payment framework.
• Standardize the Part B benefit regarding physical therapy services.
• Utilize the foundation established by APTA to assist CMS in the transition of outpatient physical therapy to value-based purchasing.

We appreciate your sensitivity to concerns about the capability of all providers to become eligible for incentives and the need to eliminate current payment problems before attempting to create this new system.  We also have questions about how CMS will select and implement reporting requirements and assessment measures.  We look forward to working with you in addressing these and other issues as the House considers this legislation and other Medicare issues this fall.  APTA is eager to work with you and your staff to ensure that legislation creating new structures in the Medicare program to provide incentives for reporting and transitioning to value-based purchasing is enacted in a fashion that ensures appropriate beneficiary access to care, reduces the administrative burden on both patients and providers, and improves the quality of care for all Medicare beneficiaries.