APTA Moves Forward With Development of an Alternative Payment System

A
new message from APTA President Paul A. Rockar Jr, PT, DPT, MS, and Steve
Levine, PT, DPT, MSHA, chair of the Alternative Payment System Task Force,
provides an update on the alternative payment system
(APS), now known as the physical therapy classification and payment system
(PTCPS), for outpatient physical therapy services. In their message, Rockar and
Levine outline the progression of the proposed payment model and the need for a
comprehensive plan "to maximize the opportunity for successful transition
to a physical therapy classification and payment system."

In
addition to the message, APTA members can access an executive summary and a
full report of the survey results that were used to refine the first APS
developmental draft, which was sent in spring 2012 to association members for
comment. The second developmental draft of the APS/PTCPS will be available to
members shortly.

APTA
expects to transition to a new outpatient therapy payment system by January 1, 2015.

Comments

In accord with my previous feedback on this payment system, I must reiterate that it will accomplish the opposite of some of the APTA's core value goals, while creating incentive to provide the least-skilled level of care, undermine our efforts to establish Physical Therapists as the "primary care providers of choice for neuromusculoskeletal disorders," and launch us backward in the progress we've made in establishing our autonomy and value in the outpatient physical therapy services world.
Please, Mr. Rockar and Mr. Levine, tell me, tell us all, how this will help those of in the outpatient world, who are not in a hospital or physician owned practice, and tell us all how this will actually improve the level of care for our patients. After reviewing the available information twice, I still do not understand how APS will be a good thing for patients and practitioners, outside of encouraging PT business owners to dilute their quality of care as much as possible to protect their profit margin.
Mr. Levine and Mr. Rockar, I have been an APTA member for many years, and you are not listening to us, you do not have our, or our patients', best interest fully in mind with this proposal. I don't know how to get in touch with you directly, so if you don't respond to this request publicly, maybe someone reading this can clue you in. You can reach me at Bruk@RealRehab.com.

Posted by Kenneth Ballenger -> >FWaDK
on 3/15/2013 3:53 PM

Call me doubtful. When insurance companies are left unchecked, they will continue to set payment as they wish and able to get by with reducing payments by 17% in one fell swoop (as we recently experienced with Humana). It's a joke...should hedge my bets by taking stock in every health insurance company. They know what they are doing to maximize profits for themselves.

Posted by Greg Given
on 3/15/2013 4:41 PM

Kenneth, your email would not go through, returned as undeliverable.
Steve Levine is the principle at FearonLevine.com and his email is stevelevine@FearonLevine.com
Email him and he is good at returning emails. We would like to know what he said.

Posted by Karen Nugent
on 3/15/2013 8:46 PM

My fear is reimbursement reductions will force us to compromise our care. If a patient needs basic unsupervised exercises no problem. But labor intensive professional services such as manual therapy, dry needling, ASTYM, etc. will be provided at an additional cost.

Posted by Charles Hollier
on 3/16/2013 7:25 AM

Agree with Kenneth Ballenger's well-spoken critique of Rockar and Levine's payment system.
Further, the 1990 Resource Based Relative Value System (RBRVS) upon which the Medicare Physicians' Fee Schedule is based was designed to reward "the thinking component of the physician-patient encounter".
The APTA Alternative Payment System uses similar language to justify its creation. Supposedly, physical therapists will conduct skilled physical therapy tests and measurements to justify the higher level APS codes (12 in all).
Instead of reward "thinking", however, the RBRVS rewards procedures.
The period of the 1990's and the first decades of the twenty first century has seen (until recently) unparalleled medical cost increases. In part, because the RBRVS has created "code inflation" whereby physicians are incentivized to code the highest level Evaluation and Management (E&M) code.
Ironically, Electronic Medical Records (EMR) use 'cut-and-paste' features to quickly puff up physicians' notes that can justify the higher level E&M codes.
One of the primary authors of the APTA Alternative Payment System owns and sells an EMR whose main feature appears to be defense against Medicare audits.
I can only imagine how future EMRs will puff up PT notes with cut and paste to allow the highest level APS code.
Tim

Posted by Tim Richardson
on 3/16/2013 6:54 PM

I find this interesting as the APTA is bending over backwards to compromise, because they have no business sense. Lets look at the AMA, every MD is required to be a member and they make sure every MD gets paid, sticking to policy to ensure that occurs. AMA threatens congress that MD's will not see medicare patients, and congress kicks the law or abandons it. We as PT's have no such unity nor is APTA's interest to keep outpatient clinics viable. Hospital's do not want OP PT due to financial profitability. How do owners of private practice pay their staff? Run a sweatshop see 20-30 patients a day to run down your therapist until they're on disability. Then try to create more "cash" programs to counter the cuts in reimbursement. Universities pump out PT students who they've made their money via loans and education. What are new grads to do? Researchers get grants and keep pumping out articles. What is the workforce to do? Get ready for functional reporting, take 50% MPPR cuts, have private insurers pay PT less then what personal trainers make, because is that what we are in insurance companies eyes?
I tell our volunteers/aides find another profession,
I'm a proud PT and is my passion but it will never bring financial security. I have another career to make money and PT has become a hobby I gladly enjoy.

Posted by NP
on 3/17/2013 1:48 AM

Everyone is a critic, but no one has any better solutions. The timed code system is quite outdated and requires extensive utilization of our and the patients time. More time does not equate to better outcomes as many articles describing over treatment of LBP have displayed. Providing quality, efficient care should be at the forefront of any and all health care professionals and they should not be obligated to spend a required amount of time with patients simply to get paid. The business sense of physical therapist is quite lacking, if you don't like the insurance contracts then don't sign them and go out of network or cash based. I don't mean to play devil's advocate, but there is plenty of money to be made if you know what your doing. Take a couple business classes, improve your manual therapy and you'll be just fine.

Posted by Noah
on 3/18/2013 12:01 PM

I fully agree with NP. Our organization is failing private practice PT's today and the whole arena of Physical Therapy as we move forward. The APTA over the past few years has been wrapped up with a "doctoring" profession but lost sight of our true skill set and value to the medicine. As a master clinician and clinic owner I see my expertise and skill being devalued as medicine continues to change and I see no support from the APTA. Physical Therapists are known to be caring, compassionate people but come on folks....we should get paid for our services at a rate that reflects our education and expertise. Frankly, I am glad I am in the twighlite of my career and have other venues of opportunity.

Posted by CK
on 3/19/2013 9:35 AM

Mr. Levine was kind enough to contact me directly through email, which I appreciate. I've posted it below. However, my questions were not answered. So I'm posting my reply to Mr. Levine below as well, hoping to be more clear on my questions;
"Mr. Ballenger,
I have read your post below that was placed on the APTA Community in response to the PTNow article: APTA Moves Forward With Development of an Alternative Payment System
I would be happy to have a conversation with you to better understand your thoughts on this matter as well as provide you with an overview of the current health policy environment that has resulted in the development of the current model and the data-driven activities that have brought APTA to this point in the process. We have collected extensive data from members in all settings, including most in private practice, who are very supportive of the overall direction of the APS, now called the Physical Therapy Classification and Payment System (PTCPS), and I would be happy to provide you some of that information as well.
Also, on the same website where you posted your comment to the PTNow article is a direct link to all APTA Board members, which includes our direct email addresses, so feel free to use that contact information whenever you would like to contact Dr. Rockar or any board member. As volunteer leaders elected to serve the best interests of the profession, this contact information is available for just this purpose.
If you would like to arrange a time to talk, please email me some times that you would be available, and I would be happy to arrange a time to discuss this issue.
Regards,
Steve"
Steve,
Thank you for your response. I was a bit surprised to be honest. I was even more surprised by direct emails that I received from grateful peers around the country that feel the same way I do.
You don’t need to have a conversation with me, you need to have a conversation with the public, and answer the questions in my post below.
How does PTCPS improve our autonomy?
How does this contribute to establishing ourselves as primary care providers of choice for neuromusculoskeletal disorders?
How will PTCPS improve the level of care that our patients receive, or rather, how will it promote anything other than minimizing the quality contact time that a therapist has with a patient?
How will this improve our already-low reimbursement?
There are many of us in the private practice world that fight like mad to be able to practice in accordance with Vision 20/20. We are the ones driving the slowly building awareness and positive reputation of the physical therapy industry in the outpatient world. It takes a massive amount of effort, sacrifice, and money to do so, and I just don’t see how PTCPS is going to help us in our battles to achieve Vision 20/20. I don’t have a hospital system behind me to fall back on for resources, and I haven’t sold out to any physician groups either. So how about those of us out there struggling to continue to provide the quality service that our patients deserve, how is PTCPS going to help us do that?
I have been enrolled in the Evidence In Motion Private Practice Management DPT course for the past several months, and as I gain more insight into running a private practice, I feel stumped when trying to figure out how PTCPS is going to be anything other than a threat to our survival.
I would encourage you to post this, with your responses, on the same page as my original posting.
Bruk Ballenger

Posted by Bruk Ballenger
on 3/19/2013 3:20 PM

Dear Mr. Ballenger: Payment has always been a hotly debated topic. When the APTA Board of Directors first endorsed the development of an alternative payment system for outpatient physical therapist services in 2011, we expected -- and welcomed – intense interest and differing perspectives from our members. We knew that without honest input from our members working in practice today, we could not develop a classification and payment system that accurately reflects and accounts for the needs of physical therapists and patients. We sincerely appreciate your questions and concerns, and we remain committed to an open and active dialogue on the proposal as it is further refined and developed. As we all know, physical therapists across the country are facing unprecedented challenges in the form of increased regulations and payment cuts. In addition to Medicare cuts that will go into effect April 1 as the result of the recent sequestration, the profession will also be faced with additional decreases in payment through the multiple procedure payment reduction. These cuts will also go into effect April 1 unless Congress acts to delay implementation. APTA has advocated intensely against these unjustified and capricious policies, and we will continue to do so. However, in the absence of congressional action, it is becoming more and more clear that payment reform is inevitable, and APTA needs to be a leader in advancing an alternative payment model that best represents the clinical expertise physical therapists can bring to the health care system. The Balanced Budget Act of 1997 mandated an alternative to the Medicare therapy cap. It was the APTA Board of Directors’ decision to collaborate with internal and external stakeholders to develop a system that best describes today’s physical therapist’s interactions with patients, rather than having a system thrust upon us by those who do not adequately understand our education, skills, knowledge, and expertise. (Continued …)

(Continuing …) As we know from health reform proposals being advanced from both ends of the political spectrum, payment in the future will be based on data that demonstrates value and patient engagement. Providers will be required to report their outcomes, and they will get paid accordingly. APTA embraces a change from today’s system -- which relies simply on performing procedures and modalities without any link to their impact on a patient’s functional improvement -- to a new model that rewards providers who provide the best known care to the right patient at the right time. This is the objective of APTA’s proposed alternative payment system, now known as the physical therapy classification and payment system (PTPCS). All along, our goal has been to reform payment for outpatient physical therapy services to improve quality of care, recognize and promote the clinical judgment of the physical therapist, and provide policymakers and payers with an accurate payment system that ensures the integrity of medically necessary services. To do this, we must transition from the current fee-for-service, procedural-based payment system to a per session payment system. APTA believes that a system that categorizes patients based on the severity of their condition and intensity of the interventions required better reflects the professional clinical reasoning/judgment and decision making by the physical therapist, improves provider compliance, reduces administrative burdens surrounding current payment models, and is consistent with and enhances payer recognition of the value of physical therapist-directed care. (Continued…)

(Continuing…) The guiding principles of the PTCPS, when understood in the context of the likely future of payment for physical therapy services, are representative of the majority's thoughts based on survey responses provided by the membership. Understandably, it is the nature of how we get to these goals that presents challenges in communicating to colleagues when movement in this arena is occurring day-to-day if not minute-to-minute, in the midst of an unbelievably challenging payment environment.
To achieve this reformed payment system for outpatient physical therapist services, changes to the existing Current Procedural Terminology (CPT) coding system, which describes services based on 15-minute time-based units and direct one on one contact, would be necessary. We understand that establishing new codes that physical therapists report for their services will be a significant change that will require therapists to learn the new codes and update billing systems. This process will require us to abandon hard earned and hard set ways of practicing and managing that will no longer work in the environment we are in the midst of navigating. We certainly understand the volatility of the current environment and the fear that “the devil you know” will be better than the “devil you don’t,” and we realize this may cause some to question the direction of the model being proposed by APTA. But please know that we have been engaged with this process for several years and have obtained advice and participation from some of the best payment and regulatory experts in the country. (Continued…)

(Continuing…) While no proposed system will be perfect or accepted by everyone based on individual biases and continuous displays of unwarranted variation in the practice of physical therapy, we believe the proposal that is now being considered by the AMA Workgroup represents the best possible option for the implementation of a payment system that most accurately reflects contemporary physical therapist practice. Further, with elimination of many of the existing codes that therapists report and the many associated edits, we believe that administrative burden will be reduced. This bundled approach to the codes will result in more appropriate valuation of therapy services that better reflects the patient's condition and the clinical judgment of the therapist. APTA’s objective is to provide the best system forward that improves quality of care, recognizes the value of physical therapist services, and ensures appropriate accountability for all health care providers. APTA is committed to helping its members manage the current challenging environment, while also positioning the profession appropriately for the health care system of the future. We encourage you to continue to engage and participate in the solution to payment reform. Sincerely, Paul A. Rockar Jr, PT, DPT, MS, President, American Physical Therapy Association, and Stephen M. Levine, PT, DPT, MSHA, Chair, Alternative Payment System Task Force