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Episode 11

Addressing Falling PT Payments

This week, a panel of APTA leaders join the show to talk about getting paid! We have VP of Public Affairs Aaron Bishop, VP of Government Affairs Justin Elliott, and Director of Health Policy and Payment Kate Gilliard. Some of what we talk about: How the payment schedule for Medicare has been stagnant for several years What APTA is doing to address the issue How consumers can help
Published on 08/03/2023
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Episode Transcript

Scott Rongo: Good morning, good afternoon, and good evening. Welcome to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. I’m your host, Scott Rongo, and I am extremely excited about today’s show. Today, we don’t have one guest, we don’t have two guests; we have three guests. We have Aaron Bishop, who’s the Vice President of Public Affairs with APTA. We have Justin Elliott, who’s the VP of Government Affairs with APTA. Then we have Kate Gilliard, the Director of Health Policy and Payment with APTA.

Welcome, and we appreciate you joining us today. Maybe as a quick start, if we could go around, do some brief introductions, and just share a little bit about yourself and what you do for APTA in your roles, and then we’ll jump into the conversation. Kate, why don’t you start us off? 

Kate Gilliard: Sure. I’m the Director of Health Policy and Payment here at APTA. I’ve been at APTA for about 5 years now. Full disclosure, I’m not a physical therapist; I’m a lawyer by training and have spent most of my career in health insurance or health care regulation. I was well-suited to join this team, focusing mostly on regulatory issues for physical therapy. But now my team also includes working with insurance companies, and we handle a lot of issues that affect the daily practice that physical therapists deal with. 

Justin Elliot: Hi there, I’m Justin Elliott, Vice President of Government Affairs here at APTA. What that means is my team and I work on issues aimed at Capitol Hill, dealing with legislation being considered by the U.S. Congress. We also handle state government affairs, collaborating with state chapters on state legislation that impacts both scope of practice and payment. Finally, we focus on member engagement through our grassroots and political action network, encouraging members to communicate and be active not only with their members of Congress but also with their state legislators.

Aaron Bishop: Good day, everybody. Again, it’s a pleasure to be here with everybody. I’m Aaron Bishop, Vice President of Public Affairs with APTA. I’ve been here for a whole whopping 19 months now, so I’m still definitely the new kid on the block, but I’m excited to be part of the team and help lead and guide our efforts.

When it comes to government affairs, health policy, and payment work, my responsibilities include regulatory work, working with insurers, our grassroots pack, as well as external-facing communications, and our strategic alliances or partnerships program. That’s all under the public affairs rubric. Prior to this, I’ve also worked at another association in a similar role and have experience from past administrations as well as on Capitol Hill. I try to bring all of that experience to the table in working with everybody. 

Scott Rongo: That is wonderful. We certainly appreciate you all taking the time out of your schedules to do this session with us. It stems from a conversation we had with Justin Moore, who is the CEO of APTA, whom you all know and work closely with. Maybe we’ll start with one of the key things he brought up on the call that we did with him.

Payments for PTs have been flat for several years, with the risk of continuously being reduced. Maybe we’ll start the conversation on what APTA is doing to help address it. How do we make sure that our providers and the PTs are being compensated appropriately for the work that they’re bringing to the communities?

Justin Elliot: Yes, I can start off with what’s been going on in Medicare, particularly the Medicare fee schedule, which has pretty much been in crisis mode for the past couple of years. Not only just for physical therapy, but for dozens of other providers, including surgeons, SLPs, audiologists, and radiologists. These year-over-year cuts have been proposed through the Medicare fee schedule due to a policy known as budget neutrality, which is forcing these cuts to come into play for all these different providers.

We’ve been successful at APTA, working with the AMA and other provider groups in getting billions of dollars in new funding to go towards the fee schedule to mitigate some of those cuts. That’s been one factor contributing to the instability right now with the fee schedule.

Now, combine that with the fact that the Medicare fee schedule is the only payment system under Medicare that does not have an annual inflationary update to keep up with the cost of doing business. That’s been a huge problem, particularly in the last couple of years where we’ve seen 8-9% inflation, and the cost of business is going up. There’s no annual adjustment, and in some cases, we’ve seen payments go down. It’s been this perfect storm that is impacting not just physical therapy but the entire healthcare system. Lots of providers are feeling this stress right now; it’s the toughest environment we’ve been in for a number of years because of the situation with payments, the increased cost of doing business, and, of course, inflation and the issues of administrative burden.

Now, I will say, what are we doing to address this? One of the things to highlight is the fact that, at least when it comes to the issue of an inflationary adjustment for the fee schedule, legislation has been introduced in this new session of Congress just a couple of months ago: H.R. 2474 Strengthening Medicare Providers and Patients Act. This bipartisan legislation would provide an annual inflationary update to the Medicare fee schedule based on what’s known as MEI or the Medicare Economic Index. This would, first of all, stop the bleeding and provide stability to the fee schedule. By providing an annual inflationary update, that means we would see actual increases going to the fee schedule. It’s something that APTA is working on; we’re working by ourselves but also with other provider groups like the AMA, the American College of Surgeons, and our friends at AOTA and ASHA to advocate for this legislation.

It does not solve every problem; there are larger reforms to Medicare that are needed, and we have a long list of issues that we need to address, but it’s a good first step and at least getting it out there because we know that Congress, as we’ve been pushing them, needs to do larger, bigger reforms to the Medicare fee schedule because it’s unstable, broken, and not working for anybody.

This, along with some other policies that APTA is pursuing, would reduce the cost of business, address things like the multiple procedure payment reduction policy, the MPPR. We are also looking to address that as well. We are looking at things like getting rid of the current direct supervision requirement for PTAs in outpatient practices, which costs money and provides a burdensome regulation. We are looking at ways not only to increase payment but also to get rid of some of these overly burdensome regulations that increase the cost of doing business. 

Kate Gilliard: What my team’s been working on, as well as everything Justin just said, has had some huge wins recently in getting CMS to reverse the decision to stop covering telehealth for physical therapists in institutional settings.

We also fixed this issue where Medicare suddenly stopped paying for remote therapeutic monitoring codes. I think that’s something that sometimes doesn’t get a lot of attention when we do work on defense, in order to make sure you can continue to get paid for the things you’re already doing.

But aside from that, looking even further down the road, we’re putting in a lot of work on the future of healthcare payment, which is quality-based payment. We know that in the long term, we’re going to continue to see private payers and public payers like Medicare continue to pivot more towards paying for outcomes versus paying for every CPT code you manage to bill.

In order to make sure those systems are fair and accurately reflect the work PTs do and the impact they have on a patient’s health, we’ve got to do a lot of legwork, making sure the measures and the systems are in place that don’t misattribute the impact PTs are doing to a different provider or vice versa, so that you’re going to get a quality payment score that’s actually reflective of what you’re doing. 

Justin Elliot: I’ll just add onto that. I know a lot of the focus is put on the federal level and what we’re doing here in Washington DC. However, APTA state chapters are also doing a lot at the state level, working with state legislatures, state Medicaid systems, and state workers comp systems to address payment and administrative burden. We’ve had a number of APTA state chapters that have been successful in enacting legislation at the state level to impact commercial payers in their state and try to increase payment for services, including Medicaid at the state level. It really is a partnership between APTA National, our state chapters, as well as our academies and sections to advance payment solutions both at the federal and state levels. 

Scott Rongo: It takes a village. Justin, you might have mentioned it in your dialogue about the administrative burden of how we stop the bleeding with cuts in terms of reimbursement, but maybe take a minute to explain what administrative burden actually means. Let’s drill into that a little bit. How can we help address this issue as well?

Justin Elliot: I like to think of administrative burden as a multi-headed monster. It takes so many forms. For us at the federal level, a couple of policies that we’re looking to try to provide flexibility and reduce costs are the legislation that APTA championed in the last Congress and that we will be reintroducing in the new Congress. This would, again, as I mentioned, change direct supervision to general for PTAs, allow PTAs to practice at the top of their scope, and provide therapy clinics the ability and flexibility to do what they need to do.

We also have legislation that’s been introduced in this Congress that would expand the use of locum tenens nationwide for PTs. Back in 2016, APTA was successful in getting legislation passed that allows for locum tenens for PTs, just like physicians have, but this was limited to just rural and underserved areas.

Our legislation in this new Congress, H.R. 1617, and the Senate Bill, Senate Bill 793, would expand that nationwide. Again, that provides flexibilities to clinics and therapists to be able to do what they need to do to run their business. But we have a lot of things happening again at the state level, which is exciting. States are doing legislation to address things like prior authorization.

This year, we have legislation in California and Maine, just to name two, that would address prior authorization. Last year, we had states like Louisiana, Michigan, Rhode Island, and even Oregon looking at prior authorization, exploring how to put some limitations on post-payment audits, underpayment claims, and looking at a broad approach to address utilization management.

There are a lot of issues out there as they relate to the cost of doing business. There are a number of policies that we are pursuing, and our state chapters are pursuing, to address it, at least through the legislative process. 

Kate Gilliard: Let me jump in and maybe even take a step back to set the table in terms of what we’re talking about when we’re discussing administrative burden. That’s really anything that costs practice time or money, that’s not directly generating revenue. Completing prior authorization requests, filing appeals, filing credentialing paperwork – you don’t get paid for that stuff. You either have to spend time doing that instead of treating patients or hire somebody else to do it.

If we can reduce administrative burden, while maybe we’re not directly influencing reimbursement rates, we’re influencing and hopefully increasing profitability. This is actually a really exciting area of policy to be working on right now because, just like Justin said, there’s action in Congress. There’s also a lot of regulatory action going on. APTA has been advocating for a long time for CMS to do something specifically about prior authorization, and CMS has finally taken up the issue. Just recently, they released three or four rules that all relate to prior authorization, standardizing the process across all the types of plans they regulate, which are Medicare Advantage, Marketplace insurance, and Medicaid managed care. If you follow policy, CMS doesn’t very often regulate all three of those programs at one time.

 

This is a really big deal. But ultimately, we’re really excited to see the outcomes of these rules because it’s going to require, like I said, streamlining prior authorization, plans are going to have to respond within certain timeframes, they’re going to have to provide clear evidentiary standards, and then publicly report data on their prior authorization processes, including the average amount of time it took for them to respond, the average rates of denials, and even rates of successful appeals. This transparency is going to really put a spotlight on plans that are abusing administrative burden as a way to dissuade people from getting care. Even though these rules aren’t final yet, we’ve already seen a number of insurance companies react. We’ve seen some of them even drop prior authorization altogether for physical therapy.

Scott Rongo: That’s probably a good transition. We can’t talk about payments and costs without bringing the conversation or guiding the conversation to insurance. What kind of work are we doing through APTA with the carriers? 

Kate Gilliard: It’s been the elephant in the room that we haven’t touched on yet. Why aren’t we talking about United Healthcare, and why are we spending all of our time talking about fee-for-service Medicare? Let me say first that there are some limitations on what APTA can do. We’re not a union, and we’re not a collective bargaining entity. We have to be really careful about not violating federal antitrust law.

We can’t influence the contracts you guys have with an insurance companies, nor can we influence the individual payment rates. However, we can do a lot of things that are going to end up having a positive impact on your business. At the national level, we maintain relationships with the biggest players like United, Cigna, Aetna. We meet with them on a regular basis. On a more regional or local scale, we have state chapters in every state. Each state chapter has a payment chair, and sometimes they even have a whole payment committee. They field questions from the chapter members, and then they often meet with the insurers themselves.

My staff and I support those chapters with strategies, resources, and even join them in those meetings. Through this work, like soft policy and soft lobbying, we can influence plans to get them to address issues like erroneous claims, denials, or system errors. Sometimes we can convince them to cover new services or reduce administrative burden, and even, quality payment programs so that high-quality PTs can make even more money.

Scott Rongo: What are things that PTs can do to help APTA? You all can only do so much. What are things that PTs, people in the community can get involved in to help with these challenges to help lessen the squeeze that PTs are seeing?

Justin Elliot: The first thing I would recommend for folks, if they’re members of APTA, is to visit the State Payment Advocacy Resource Center, also known as SPARC, a new tool that was developed and rolled out last year, by APTA and APTA Private Practice. It is a one-stop shopping site for background information and tools that individuals as well as individual practices can utilize to advocate for themselves on payment and administrative burden issues. When we talk about it taking a village, this is something that everyone who’s a member of APTA can do. They can go to this site, APTA.org and look under the payment section. You’ll see a link to the State Payment Advocacy Resource Center, and go there and look at those tools, look at that information that’s there to help individuals to fight back on some of these policies that are costing money and reducing payment. That would be one step that I think everyone who’s a member could take.

Another thing that members can do is, at the state level, get involved with your state chapter. State chapters have a number of avenues for folks to get involved in advocacy, whether it’s state legislative advocacy or payment advocacy. If you’re passionate about payment, talk to your state chapter. Most chapters, as Kate mentioned, have payment committees, and they’re there to address things like Medicaid payment, commercial payers in your state, and of course, things like workers’ comp. Of course, if you’re not a member of APTA, the number one thing you can do is to become a member of APTA to help us fight on these issues. 

Scott Rongo: That message was delivered by Justin more certainly to get the word out. Aaron, what are your thoughts there?

Aaron Bishop: In addition to working with payers, as well as our individual members and chapters, we also try to educate consumers. We believe that having an educated consumer base can really assist us when it comes to advocating at the insurer base level, at the state level, as well as at the federal level. One way in which we do this and to make sure that the work that we’re doing is resonating with consumers is by collecting data. We’ve done so in 2007, we’ve done so in 2016, and then in 2021, we followed up by conducting an additional research study that was part of this ongoing information-gathering strategy.

 

The study was really designed to assess public opinion of physical therapy services, attract consistencies, changes in public perception, and identify opportunities to improve public awareness. We’ve learned that this has really paid off and that consumers really have a good understanding of the benefits that physical therapy services provide. We’ve seen that change throughout the years, looking at 2007, 2016, and 2021. Just to provide a few specific areas in which we’ve seen this change is that, as an example, consumers see the importance of improving their range of motion and mobility or level of physical activity. While physical therapy usage hasn’t changed since 2016, the reasons for seeing a physical therapist have. There’s now a greater emphasis on improving range of motion. 

In addition, consumers place less emphasis on injury and recovery. This positive change coincides with work that APTA has done in our public relation efforts. The focus is less on the bread and butter issues that PTs already own in the mind of consumers and more on the importance of movement and PTs as movement experts in the overall health and wellness equation. That’s one area in which we’ve seen growth in consumers and helping us push agendas.

We also know that PT users have significantly decreased the use of prescription pain meds since 2016, and this coincides with APTA’s increased focus on pain management. Then finally, physical therapy users were more likely, in 2021 than they were in 2016, to say that they would consider seeing a PT without first receiving a referral. Although a majority of the respondents in 2021 still said they would not consider seeing a PT without a referral from their primary care provider, the sentiment among physical therapy users has improved since 2016. In 2021, 33% of physical therapy users said that they would go directly to a PT versus 23% in 2016.

We’re seeing that consumers understand what PTs do, really see us as being experts in the area of movement, seeing that we are an alternative to opioids and therefore opioids addiction, as well as, more willing than not, to go straight to a PT as opposed to going to their primary care provider first. We see a relationship there. We’re seeing again that increase of people willing to just say, “I realize that I need a PT for these various healthcare conditions, and I’m willing to go there on my own.” 

Scott Rongo: Kate, I understand APTA has influence in CPT codes. Can you elaborate a little bit on the involvement you all have?

Kate Gilliard: As the association representing physical therapy, we have a permanent seat at the table with the American Medical Association’s CPT and RUC committees. Those are the committees that create CPT codes from scratch. The CPT panel defines the codewhat goes into it, what does the provider actually do? Then the RUC committee is the one that values it to determine how much it should be paid. Ultimately, payers decide how much they want to pay on their own, but the relative value, how much a code gets scored compared to other codes, is important. So, we’ve been driving new codes coming out of there for physical therapists for a long time, but we’ve had some success recently.

We got the remote therapeutic monitoring codes to come out that were based on some similar codes that had previously existed. But we also just had some success getting some caregiver training codes put out by the committee, and we’re hopeful to get those included in the Medicare physician fee schedule this summer. Hopefully, that work that a lot of physical therapists already do and just don’t have a code to bill for it will continue to get more codes to represent that work so that you can get paid for the things that you do.

Scott Rongo: That’s great. I got to tell you; I am learning all sorts of things that APTA does today. I feel like there’s a lot that you all are doing that perhaps is just unknown. How are you educating people on the work that you all are doing overall?

Justin Elliot: First, internally, we are always trying to educate our members through all of our communication channels, social media platforms, and podcasts like this one about the work that we are doing and the issues that we are advocating on. But the other part of that equation is educating external groups, particularly policymakers, about what is important to the PT profession and why issues of payment and administrative burden are so important.

Just two examples of that would be: APTA is involved with a group called the National Conference of State Legislators (NCSL), a national organization that is comprised of the 7,400-plus state legislators from all 50 states. This summer, we’ll be going to their annual conference, talking a lot about payment at the state level and administrative burden. In July, we’ll be rolling out our new national advertising campaign aimed at NCSL. That’s going to really be focused on things like administrative burden, prior authorization, and Medicaid payment rates.

At the national level, at APTA, we host our annual PT Day on Capitol Hill, and for 2023, that’s coming up in just a few short weeks on September 23rd and 24th here in Washington D.C. We have over 400 people registered so far, and we’ll be going up to Capitol Hill to talk about Medicare payment, the need for inflationary updates, and administrative burden issues like the PTA issue and locum tenens. Hopefully, folks will be able to join us as well next month here in DC to educate these policymakers not only about payment but also about what physical therapy is about, the economic value we bring to the healthcare system, and how we can be part of the solution when it comes to healthcare. 

Scott Rongo: That is great. Kate, Justin, and Aaron, we are just about out of time, but anything that you want to leave our audience with?

Aaron Bishop: There was one thing I’d like to add, and I think Justin just teed us up pretty perfectly for this, and it’s regarding economic value. We’re in the midst of completing an Economic Value of Physical Therapy report, which is a landmark analysis of the value of a range of physical therapy interventions. We know that as a profession, the health benefits and effectiveness of our interventions and the value we provide to the healthcare sector are proven in the research literature. However, despite this strong scientific base, we lack a high-quality study examining both effectiveness and the economic benefit that physical therapy provides.

Therefore, we commissioned an analysis of the value of a range of physical therapy interventions to build a robust picture of our high-level impacts and the value this provides to the healthcare sector. We believe that this study will find that the treatments by physical therapists deliver both health and economic benefits. The interventions will be clinically effective and deliver net economic benefits with quality of life improvements exceeding treatment costs. If proven true, which we believe that’s going to be the case when we have the final results, we’re going to plan on using this in all of our advocacy efforts.

We’d like everybody to know to be on the lookout for this work to be released in the fall, most likely September, October, or November.

Scott Rongo: We will certainly be on the lookout for it. Aaron, Justin, and Kate, we very much appreciate the effort and work that you all are doing through the APTA to help support our PTs. We appreciate you taking the time to spend with me here today to educate our listeners on all the good work that you all are doing. Thank you very much. Thank you to our audience as well for tuning into the Therapy Matters podcast, your one stop resource for expert insights and advice on everything therapy and rehab. We look forward to seeing you guys all in the next episode. Thanks, and have a great rest of the day.