1. Overview: APTA Perspectives Alternative Payment Methodology

2. Making the Case for Payment Reform Recommendations from “Phasing Out Fee for Service” (NEJM)  Transition to Quality and Episodic methodologies should begin with “Blended” approaches  Site Neutral Payments / Provider Neutral Payments  Value “Patient Management” over “Procedures”  Risk Sharing / Innovations Rewarded  http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

3. Methods of Payment Reform

4. Payment of the Past  Paid for usual and customary services  Paid what we billed  Unrestricted number of visits  Length of stays 30-40 visits /over months/years  Paid for usual and customary services  Paid what we billed  Unrestricted number of visits  Length of stays 30-40 visits /over months/years

5. Future Payment Based On: Patient presentation and therapist clinical decision-making  Professional skill and judgment  Mental and physical effort  Psychological stress of impact of interventions  Length of involvement to a limited extent In other words, payment based on:  The clinical decision making needed to address the severity (complexity) involved  The intensity of the services provided to the patient to meet their needs to progress towards return of function Not primarily on time spent

6. Improving Value and Affordability Old ModelNew Model

7. THE EVOLUTION OF APTA’S MODEL FOR PAYMENT REFORM

11. Current CPT Perspectives Reporting Under a Per Session Payment Methodology Reporting elements being considered: Up to 5 levels of interventions: Combine elements of patient severity and intensity of provider work  Low Severity/Low Intensity  Moderate Severity/Low Intensity  Moderate Severity/Moderate Intensity  High Severity/Moderate Intensity  High Severity/High Intensity

12. Current CPT Perspectives Reporting Under a Per Session Payment Methodology Basic elements include:  12 codes describing evaluations (4 PT, 4 OT, 4 AT)  Majority of 97000 CPT codes describing interventions collapsed into per session code structure  Select services remain as “separately reportable” (~14 services)  Bundling of high volume procedure codes into one code with Provider reporting a level (1-5) that their clinical work reflects;  Levels of intervention, reported based on complexity/severity of patient and intensity of therapist work

13. Trends in Therapy Services To Demonstrate Value and Decrease Administrative Oversight Added requirement to report codes to indicate progress made towards return of function through claims process Therapist reporting elements of practice that reflect Quality of services Reporting mechanisms that reflect level of clinical decision making based on patients presentation Demonstrate Value and things start happening......

14. PT, OT Evaluations 3 I nitial, D evelopment of POC 1 Re-Eval, est. POC

15. Evolution of Model Collapsing Levels of Interventions Intensity of Intervention Severity of Patient @ Visit LowModerateHigh Low 123 Moderate 234 High 345

16. Current CPT Perspectives Reporting Under a Per Session Payment Methodology Characteristics of Reporting Elements: Level 1 Severity  Patient presentation: Stable  Personal/environment: No impact on management  Function: Per assessment instrument, minimal restrictions (5- 24%)  Prognosis: certain, predictable Intensity  Straightforward clinical decision-making  No to minimal adjustment to supervised management  Minimal risk

17. Current CPT Perspectives Reporting Under a Per Session Payment Methodology Characteristics of Reporting Elements: Level 3 Severity  Pt. Presentation: Condition/complaints actively evolving, but predictable, with impact from co-morbidities  Personal/environment: Present some challenges to pt. management  Function: Per assessment instrument, moderate restrictions (25-49%)  Prognosis: predictable but with risk for delayed progress Intensity  Straightforward clinical decision-making  intermittent adjustment required based on patient response  Elements of supervised and direct contact management  With risk factors taken into consideration through plan

18. Current CPT Perspectives Reporting Under a Per Session Payment Methodology Characteristics of Reporting Elements: Level 5 Severity  Pt. Presentation: Condition/complaints actively evolving, in an unpredictable manner, with unstable co-morbidities  Personal/environment: negatively impact pt. management  Function: Per assessment instrument, significant restrictions (> 50%)  Prognosis: variable, requiring prioritization of objectives Intensity  Complex clinical decision-making  Immediate response to management of response to treatment  Continual adjustment of elements of treatment provided in direct contact with patient  risk factors influencing development and management through plan of care

19. Timeline: CPT Process StageTimeline ActionOutcome AMA CPT – PM&R Workgroup Formed October 15, 2012Presentation of AMA /CPT charge for WG task: revision of 97000 Preliminary discussion of WG expectations, 13 stakeholders WG Meeting-face to face January 25, 2013 May 16, 2013 October, 2013 Nov. 4 2103 All stakeholders to bring their concepts for revisions to the meeting APTA and AOTA describe each of their approaches to revisions WG Meeting- teleconferences 8 March 12–Dec. 4, 2013 Discussions regarding scope of practice, use of current code set and elements of agreement Attempt to merge common elements Presentation to CPT Editorial Panel February 6-8, 2014 WG collaboration presented to editorial panel for discussion and consideration postpone a decision on new codes to future meeting to allow additional time for pilot testing and refinement WG Meetings-Testing of Model for levels of interventions Through October 2014 WG will work on refining language to utilize in testing model-outreach for participation in all OP rehab settings Final Proposal to Editorial Panel by February 2015, publication of revisions to PM&R codes Jan.1, 2016

20. The RUC Process Survey for Work  Clinical vignette  Reference Code list  Per unit/procedure vs. per visit/session  Pre, Intra & Post Service time  Estimated utilization frequencies  APTA will be soliciting/facilitating Therapists to complete Surveys

21. Overview Alternative Payment Methodology Significantly change the model of payment:  Demonstrates use of clinical judgment  Payment is influenced by patient characteristics, intensity of clinical work with reporting of outcomes that help demonstrate value  Administratively burdensome policies lessened with focus moving away from control of utilization and towards managing patient progress towards functional change and outcomes

22. Web Resource – APTA.org

23. New Payment Model: Innovative Approach to Advance PT Practice Profession will either drive change or… it will be driven by others!