Let’s take a little trip to the past: the year was 1997. “Titanic” was smashing box office records as moviegoers flocked to theaters for their third or fourth viewing; “Wannabe” by Spice Girls was hitting the airwaves on every Top 40 station; and large-scale healthcare reform was barely stepping into the legislative limelight. To hamper exorbitant healthcare spending, the Clinton administration signed the Balanced Budget Act into law and thus, introduced the Medicare therapy cap. Fast forward 20 years, and a lot has changed: for one thing, I’ve long since removed that Soundgarden poster from my bedroom wall. But at least one thing remains the same: the cost of healthcare continues to be a tremendous burden, and the Medicare therapy cap for PT, OT, and SLP in 2017 continues to cause major headaches for patients and providers alike.
It’s Detrimental to Patients
In its current form, the therapy cap can throw a lot of roadblocks into the patient care path, preventing therapists from doing what they do best: helping patients improve function and mobility. But the tangled web of rules, regulations, and myths incites much confusion within the rehab therapy community. For one thing, many providers mistakenly assume that Medicare will not pay for services beyond the initial $1,980 limit—with or without the KX modifier. Some providers are also hesitant to enter the exceptions process due to Medicare’s murky definition of “medical necessity,” especially as it relates to maintenance care coverage. Of course, Medicare covers maintenance care as long as it’s medically necessary. But again—and as we learned from Jimmo v. Sebelius—defining medical necessity isn’t always cut and dried.
Furthermore, many rehab therapists have been led to believe that frequently exceeding the cap could be a red flag to Medicare—which could increases their chances of being audited. As providers feel pressured to press pause on the course of care, these breaks in the care plan make patients vulnerable to regression and re-injury. Some patients may even end up turning to more invasive—not to mention expensive—care options, which leads to unnecessary spending in the long run. So in the end, the therapy cap that was supposed to keep the healthcare system from hemorrhaging money could actually—theoretically—create even more unnecessary spending.
It creates a serious dilemma for speech and PT patients.
It also means that some patients might have to choose between physical therapy and speech therapy, both of which are covered under the same cap. In the event of a major cardiac or neural event—such as a stroke—a patient might find that the allotted amount is only enough to cover one or the other, leaving that patient with an unfathomable choice: mobility or communication.
Professional associations are on board.
According to APTA Chief Executive Officer Justin Moore, the fundamental problem that the cap was intended to solve in 1997 still exists in 2017: the yearly allowable amount is so low that strictly adhering to it would prevent patients from obtaining crucial, medically necessary treatment. True, there’s an exceptions process in place for those who exceed the therapy cap, but that process is often disruptive and can create gaps in ongoing treatment plans. This past July, Moore—along with representatives from the American Speech-Language Hearing Association (ASHA) and the American Occupational Therapy Association (AOTA)—reiterated this very point to the House of Representatives Subcommittee on Health. As he put it, "This pattern of yearly extensions without a permanent solution creates uncertainty for beneficiaries and providers, threatens access to care, and is not in the best interest of patients, providers, or the Medicare program."
Time is of The Essence
Granted, there are inevitable costs associated with a repeal, but—as history has taught us—those costs will only increase the longer Congress delays action. According to the APTA, “The [current] effort to end the therapy cap marks the 17th attempt to move away from what originally was intended to be a temporary provision adopted as part of the 1997 Balanced Budget Act.”
The updated medical review process shows promise.
But, Moore and other rehab therapy leaders are advocating for a more permanent fix. During his testimony on Capitol Hill, Moore referred to the manual medical review process changes implemented in 2015, noting that this update “set the stage for viable review programs that would ensure appropriate spending without resorting to caps.” Based on the overall success of these changes, he suggested replacing the cap with a "thoughtful medical review that is more targeted, ensures that care is delivered to more vulnerable patients, streamlines the ability to deliver that care, and ensures the long-term viability of the Medicare program.”
The Rehab Community Must Act Now
Language in the Balanced Budget Act indicated the cap would serve as a temporary fix until a better solution became available. By now—thanks to programs like PQRS, FLR, and manual medical review—we’ve collected enough data to support the importance of rehab therapy and solidify its role in the recovery and habilitation processes. With 177 cosponsors, the current bill to repeal the therapy cap (HR 807) has strong bipartisan support. That—coupled with the encouraging results of medical review update and strong grassroots efforts in all areas of the rehab therapy profession—puts our industry in the perfect position to create real change and maybe, just maybe, nix the therapy cap for good.
Ready to stand up for your profession and join the movement? Here’s how you can take action right now:
- Join APTA and stay up to date on advocacy efforts.
- Be an active member of PTeam—APTA’s advocacy team.
- Contact your representatives about repealing the Medicare therapy cap.
- Visit www.apta.org/takeaction to stay current on various advocacy efforts.
Clearly, the American healthcare system is in flux. As Congress dukes it out over healthcare reform and insurance payers adjust their reimbursement models, fixing and removing outdated policies is inevitable. By advocating for this necessary change now, rehab therapists can help push the leviathan-sized healthcare reform process onward and upward. Sure, crushed velvet t-shirts and Doc Martins have made a comeback, but ’90s healthcare policy is less than fashionable. It’s time for CMS to get with the times—and that’ll only happen if the community stands together and rallies as a united front.