The Medicare Therapy Cap and the Imperative for Physical Therapist Engagement in Policy

I find physical therapy to be a rewarding career. My favorite achievement is helping people reach milestones they never thought possible: walking for the first time after a stroke, sleeping through the night without pain, picking up a grandchild with ease. Every morning, I genuinely love going to work to see my patients achieve what they once thought impossible.

[Read also: Occupational Therapy Reimbursement in a Payer-Driven Model]

However, there is something that may threaten our ability to help patients achieve these milestones: ill-considered policy. Policies dictate our autonomy and capacity to treat our patients. Think about the times you had to call an insurance company and convince them to authorize visits for one of your patients. Or when you were forced to limit your plan of care in order to avoid exceeding the Medicare Therapy Cap. Or the physician referral your patient needs in order for you not just to perform an evaluation but also to treat that person’s chronic low back pain.

For these reasons, it is our responsibility as professionals to understand healthcare policy, serve as patient advocates, and inform our patients when their access to services is threatened. I do believe it is unethical for physical therapists to be apathetic in the political process. We are, after all, at the front lines in transforming healthcare (download Transforming Health Care: The Public Policy Priorities of the American Physical Therapy Association, 2017-2018 (.pdf).

The Ethical Imperative

Having a voice in the political sphere isn’t free; someone has to pay for it. If we agree that physical therapy benefits patients and policies control patient access to physical therapy, then it should follow that a political voice for physical therapy is essential to patient care. There are only so many ways to create an influential political voice. We can postulate the following systems for mobilizing a collective voice:

1. There is an onus on every practicing physical therapist to directly participate in advocacy efforts. Each physical therapist must make an intellectual or manual contribution to political endeavours.
2. No individual physical therapist need make a direct contribution to policy efforts but instead supports (via donations, membership dues, etc.) the work of a professional advocate for physical therapy. This enables a dedicated workforce of people who can focus on legislation that may impact physical therapists and patients.
3. Some combination of A and B above.

Personally, I favor a strong commitment to option C, but what should be inescapable is the idea that if a physical therapist is neither directly contributing intellectually or manually to policy efforts nor paying dues to support professional advocates, that therapist is shirking an ethical obligation.

The Medicare Therapy Cap

What political topic do I see as being the most imminent for patients at the moment? Physical therapists and the American Physical Therapy Association (APTA) have been fighting to repeal the Medicare Therapy Cap for 20 years. (The Medicare Therapy Cap encompasses Medicare Part B outpatient physical, occupational, and speech therapy services in private practice offices, outpatient hospital departments, and skilled nursing facilities when Part A does not apply). Originally passed with the Balanced Budget Act of 1997, the Medicare Therapy Cap limits a beneficiary to $1980 of physical and speech therapy combined while occupational therapy has its own separate cap (also $1980). Following the passage of the Act, Congress passed a bill that allowed Medicare beneficiaries to receive up to $3700 of combined physical and speech therapy and $3700 of occupational therapy if medical necessity could be proven (called the “hard cap” and applied using the KX modifier).

Due to Congressional inaction, however, the policy that allowed an extension of medically necessary therapy services up to $3700 expired and a new cap of $2010 went into effect on January 1st, 2018. Therefore, once a beneficiary meets the $2010 mark for physical and speech therapy combined or occupational therapy Medicare will not pay for therapy. Because the former policy is expired, there is little that can be done regarding the implementation of the new cap.

What does this mean for us as providers? It means we will only be able to treat our most vulnerable patients for approximately 16 visits per year. What does this mean to patients? It means if a patient has a stroke and needs both outpatient physical and speech therapy, these 16 visits will need to be divided in order for the patient to have their physical, cognitive, and speech deficits addressed and treated. It means if a patient has multiple surgeries or injuries in a year, they may not receive the treatment they need. It means if someone has chronic pain but is out of visits, they may have to undergo more costly procedures or risk being prescribed opioid medication

Potential Solutions on the Horizon to Remove the Medicare Therapy Cap

Dan Ciolek, American Healthcare Association (AHCA)/National Center for Assisted Living (NCAL) associate vice president and advocate for therapy services explained in an email update (pdf) from January 1, 2018 that if no prompt action is taken by Congress, Medicare beneficiaries numbering in the hundreds of thousands, will be hurt by this cap, and this group includes many residents of skilled nursing facilities and assisted living residences. According to a recent news article in Provider Magazine: 

“What is lacking right now is the legislative vehicle to put the policy in place, as well as a funding solution. While there is discussion the therapy cap repeal could be placed in must-do funding bills in January, or separate possible measures in February or March, there is no guarantee that will occur.

Fortunately, a bipartisan agreement called the Medicare Access to Rehabilitation Services Act has been reached to permanently repeal the Medicare Therapy Cap altogether. This piece of legislation has been introduced into the House of Representatives where it currently awaits a vote. This is where physical therapists can play the advocate role. The article from Provider Magazine discusses these bills: “A Senate bill to repeal the caps (S 253) is currently co-sponsored by more than one-third (37) of senators, while a House bill (HR 807) is co-sponsored by a majority (229) of representatives.”

[Read also: How CMS’ Proposed Changes to the SNF PPS Could Hinder Access to OT Services]

As therapy professionals, we need to inform our patients and their families about this bill and encourage them to contact their legislators in support of it (number HR 807 for the House and S 253 for the Senate). It is also our ethical responsibility to contact policymakers with the same message, fighting for access that is based on medical necessity, not some arbitrary dollar amount.