The Road to a New Payment System for Physical Therapy

Today's post comes from Ann Wendel, PT, ATC, CMTPT, of Prana Physical Therapy. Thanks, Ann!

Recently, the APTA posted information proposing an Alternative Payment System (APS). The proposed system would have three evaluation codes and nine treatment codes for physical therapists to use. According to the APTA, their goal with APS is 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.”

The APTA is proposing to “reform payment for outpatient physical therapy services by transitioning 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.”

While I believe that all physical therapists would agree that a simpler coding system is desirable (especially if it improves quality of care, promotes the clinical judgment of physical therapists, and enhances payer recognition of the value of physical therapist-directed care), not all physical therapists believe that the APS as proposed is the best system to adopt.

Last week’s #solvept discussion involved physical therapists employed in various settings problem solving the issues with both the current and proposed payment systems. Some of the statements that stuck in my mind include:

• Severe does not equal severe (what is perceived as high severity by one therapist may be perceived as low severity by another)
• Complexity does not equal complexity (see above)
• If treatment of a “high severity” patient pays more, one can easily abuse the system
• If four “low severity” patients in an hour pays the same as one “high severity” patient per hour, then physical therapists are still being paid on a “time = money” scale rather than a “value = money” scale
• Severity and complexity may have nothing to do with outcome, and the public, physical therapists, and payers need meaningful outcomes tied to cost/payment
• The severity/complexity model may be more useful in some settings (e.g., acute care) than in others (e.g., outpatient orthopedics) leading to the question: “Is more than one payment system needed to address all physical therapy settings?”

It was a good discussion, fueled by the passion of those therapists present. I emphatically agree with what one therapist said at the end, “I love treating patients. I just want to get paid for doing what I love!” I find myself saying this over and over lately; I just want to make a living doing what I love, and it is getting increasingly more difficult to do so.

The Physical Therapy Business Alliance (PTBA) addressed the issue of making a living while saddled with educational debt with an official statement regarding the APS in an Evidence in Motion blog post on June 13. Here are the highlights of the post that caught my eye:

• A four-unit visit in 2012 is paid at 32% less than 20 years ago (actually closer to 40% when accounting for the impact of group therapy billings and MPPR).
• Debt burden for becoming a licensed physical therapist (attaining a DPT) has risen by approximately 30% in this time frame.
• Because of rising tuition rates and declining reimbursement and salary rates, it is becoming increasingly difficult to draw candidates to become physical therapists. This situation will become a greater problem due to the demand for physical therapy services to care for an aging population.
• Lack of unrestricted Direct Access to physical therapy on a national level and lack of use of physical therapists as the point of access for musculoskeletal conditions leads to rising healthcare costs in an already overburdened system.

The PTBA proposed a solution: a value-driven payment model (VDP) that rewards physical therapists for clinical outcomes and performance. PTBA states:“It is the position of the PTBA that the time for radical payment reform is now. As a professional association, PTBA is committed to the Triple Aim value of health care reform, which is comprised of 1) measurable quality care, 2) exceptional patient experience, and 3) lower cost of care. At its core, the Triple Aim concept is fundamentally rooted in the concept that payment methodology should be based on a balance of quality and cost.”

The PTBA proposes: “The establishment of a simple and transparent model in which three timed codes for care rendered by or under the immediate direct supervision of the physical therapist” (see below).

‍

‍

They also propose that “payment would include outcome-driven incentives such that providers are rewarded for outcomes and efficiency.”

I expect that over the next few months the discussion will continue until legislators decides upon a new payment model for physical therapists. I think we can all agree that the time has come for the public and medical community alike to recognize physical therapists as a valuable, autonomous member of the healthcare team. If we all want to continue to do what we love, it is time to get involved in the discussion.