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APTA Screenplay

What is the Therapy Cap? Created in the Balanced Budget Act (BBA) of 1997 Two Annual Caps: 1) $1920 cap on PT/SLP Combined 2) $1920 cap on OT Does not take into account clinical condition Therapy cap exceptions process created in 2006 to allow patients to exceed the cap if medically necessary

What is the Sustainable Growth Rate (SGR)? Created in the Balanced Budget Act of 1997 Payment formula for all outpatient Medicare services Intended to ensure that yearly increases match the growth in GDP Flawed formula results in the need for a yearly “doc fix”

SGR Created in 1997 Balance Budget Act (BBA) Fixed 17 Times Cost of 16 Fixes: More than a permanent fix Cost to Fix Permanently: $120- $140 billion Therapy Cap Created in 1997 Balanced Budget Act (BBA) Fixed 12 Times Cost of 12 Fixes: More than a permanent fix Cost to Fix Permanently: $8.8 billion

House Energy and Commerce Senate Finance House Ways and Means

Repeals the Medicare therapy cap Retains manual medical review at $3,700 for 1 year Transitions to a new medical review system in 2015 with a prior authorization mechanism for approval of blocks of visits Replaces current functional limitation reporting with new therapy data collection system (around 2017) Starting in 2015, claim form must indicate if the service is provided by a therapy assistant

Late- March 12 Month Patch on SGR/Therapy Cap S SGR, Therapy Cap Repeal OCO Offsets 12 Month Patch on SGR/Therapy Cap Mid - March H.R Passes on House Floor SGR only with ACA offset S SGR, Therapy Cap Repeal, No Offsets February H.R 4015 Introduced SGR only S Introduced SGR only December House Ways and Means Committee SGR only bill Senate Finance Committee SGR, Therapy Cap Repeal bill

The 12 Month Patch Averts the 24.1% SGR cut for 1 year Extends therapy cap exceptions process for 1 year How the $20 Billion Patch is Paid For SGR Transitional Fund- $2.3 billion Value Based Purchasing Program for Skilled Nursing Facilities- $2 billion Cuts to clinical labs- $2.5 billion End Stage Renal Disease bundle changes- $1.8 billion Cuts to radiology services- $.2 billion Misvalued Code Authority- $4 billion Medicaid Disproportionate Share Hospitals (DSH) Reductions- $4.4 billion 1 Year extension of Medicare Sequester (2024) - $4.9 billion

Repeal & Reform of the SGR Repeal & Reform of the Therapy Cap and support for the Senate provision Awareness on Issues Surrounding MMR & FLR (optional) Cosponsor S. 367 and H.R legislation to show support for repealing the cap

The therapy cap is arbitrary and does not take clinical condition into account The therapy cap affects those that need therapy the most APTA and the therapy community has worked in good faith to find a viable cost saving alternative to the cap SGR and therapy cap were created together and they should be repealed together Support the Senate provision on therapy cap repeal and help provide stability for providers and patients Cosponsor S. 367 or H.R. 713

Ben Cardin (D-MD) Democratic Bill Sponsor Susan Collins (R-ME) Republican Lead Sponsor

Ron Wyden (D-OR) Chairman, Senate Finance Orrin Hatch (R-UT) Ranking, Senate Finance

Jim Gerlach (R-PA) Republican Bill Sponsor Xavier Becerra(D-CA) Democratic Lead Sponsor

Dave Camp (R-MI) Chairman, Ways & Means Sander Levin (D-MI) Ranking, Ways & Means Fred Upton (R-MI) Chairman, Energy & Commerce Henry Waxman (D-CA) Ranking, Energy & Commerce

Joe Pitts (R-PA), Chairman, Energy and Commerce Health Subcommittee Frank Pallone (D-NJ), Ranking Member, Energy and Commerce Health Subcommittee Kevin Brady (R-TX), Chairman, Ways and Means Health Subcommittee Jim McDermott (D-WA), Ranking Member, Ways and Means Health Subcommittee Mike Burgess (R-TX), SGR Repeal Bill Lead Sponsor John Rockefeller (D-WV), Chairman, Senate Finance Health Subcommittee Pat Roberts (R-KS), Ranking Member, Senate Finance Health Subcommittee

Omnibus Budget Reconciliation Act of 1989 Stark Law Created (Stark 1). Becomes effective in 1992 Barred self-referrals for clinical laboratory services under Medicare Omnibus Budget Reconciliation Act of 1993 Congress added services like PT, anatomic pathology, imaging and radiation therapy services (among others), to the definition of designated health services (DHS). Greatly expanded the in-office ancillary services (IOAS) exception, which subsequently included DHS. Physical therapy was caught up in this exception. Known as “Stark II”

Why is this a problem? Stark laws originally passed to stop physicians referring for profit, yet exception allows physicians to make money for referring services to their own practice Stark II (the exceptions) was originally for patient convenience. If these services could be provided in the “waiting room,” then it would serve the patient. PT services are rarely provided even on the same day of a patient’s initial visit Incentive to refer is hurting providers and access for patients PTs do not control these referrals Unnecessary care Increasing utilization numbers Leads to increased scrutiny from CMS

What are we doing? Alliance for Integrity in Medicine (AIM Coalition) President’s budget proposes removing these services Advocating with other stakeholders and entities to endorse closing the loophole The Promoting Integrity in Medicare (PIMA) Act H.R This legislation removes PT, anatomic pathology, advanced imaging, and radiation therapy services from the in-office ancillary services exception. Does NOT eliminate the exception overall Rural exception already exists in statute Exception for truly integrated facilities (Mayo, Cleveland Clinic, etc.)

Who Else Has Weighed In? Removal of services in the President’s Budget CBO score of the President’s Budget Think tanks – Looking at ways to improve efficiency Studies- GAO, Jean Mitchell

Ask your House Representative to support or cosponsor H.R Ask your legislator to support using the removal of physical therapy from the in-office ancillary services exception as a budget offset

Undercuts the Purpose of the Stark Laws by allowing physicians to make money from their referrals – remember, each referral is an actual patient! Coordinated care should not be defined by profit Violates the spirit of the in-office ancillary services exception because patients rarely see a physical therapist on the same day of their initial visit Increases the incentive for physicians to refer patients for services they don’t need, thereby hurting the patient and increasing utilization. Making this change reduces Medicare abuse Finally…This policy change saves billions of dollars, so it can help pay for a permanent repeal of the SGR and therapy cap!

Jackie Speier (D-CA) Democratic Bill Sponsor

Ron Wyden (D-OR) Chairman, Senate Finance Orrin Hatch (R-UT) Ranking, Senate Finance

Dave Camp (R-MI) Chairman, Ways & Means Sander Levin (D-MI) Ranking, Ways & Means Fred Upton (R-MI) Chairman, Energy & Commerce Henry Waxman (D-CA) Ranking, Energy & Commerce

Joe Pitts (R-PA), Chairman, Energy and Commerce Health Subcommittee Frank Pallone (D-NJ), Ranking Member, Energy and Commerce Health Subcommittee Kevin Brady (R-TX), Chairman, Ways and Means Health Subcommittee Jim McDermott (D-WA), Ranking Member, Ways and Means Health Subcommittee John Rockefeller (D-WV), Chairman, Senate Finance Health Subcommittee Pat Roberts (R-KS), Ranking Member, Senate Finance Health Subcommittee

National Health Service Corps (NHSC) created to provide care to underserved populations Provides student loan forgiveness for 2+ year commitment (up to $50,000 per year) Serves 9 million Americans with 82% retention rate Successful program that continues to receive increased funding in a difficult time for funding

Physical Therapist Workforce and Patient Access Act (H.R. 1252/S. 602) includes physical therapists in the NHSC Ask your legislators to cosponsor this legislation This is your “Winner for Best Plot”! Increases access to physical therapy in underserved areas Supports growing demand for physical therapists Legislation is budget neutral

This legislation matches the goals and mission of the NHSC Can alleviate demand on other primary care providers to increase those served Provides for greater patient access to rehabilitation No rehab currently represented in program NHSC is successful pipeline for providers 82% retention rate Meeting the workforce needs of underserved areas Demand for PT continues to grow And the finale…Legislation is budget neutral!!

This legislation matches the goals and mission of the NHSC Can alleviate demand on other primary care providers to increase those served Provides for greater patient access to rehabilitation No rehab currently represented in program NHSC is successful pipeline for providers 82% retention rate Meeting the workforce needs of underserved areas Demand for PT continues to grow And the finale…Legislation is budget neutral!!

Jon Tester (D-MT) Democratic Bill Sponsor Roger Wicker (R-MS) Republican Lead Sponsor

John Shimkus (R-IL) Republican Bill Sponsor Diana Degette (D-CO) Democratic Lead Sponsor

Tom Harkin (D-IA) Chairman, HELP Lamar Alexander (R-TN) Ranking, HELP Fred Upton (R-MI) Chairman, Energy & Commerce Henry Waxman (D-CA) Ranking, Energy & Commerce

Joe Pitts (R-PA), Chairman, Energy and Commerce Health Subcommittee Frank Pallone (D-NJ), Ranking Member, Energy and Commerce Health Subcommittee Bernard Sanders (I-VT) Chairman, Senate HELP Subcommittee on Primary Health and Aging