The rehab therapy industry is no stranger to payment cuts, especially at the hands of CMS. But what if we were to look at CMS as a business? Humor me for a moment. CMS focuses intently on remaining budget-neutral, right? Whenever its expenses increase, it must reduce its costs and bring in more revenue. That’s a pretty straightforward business strategy. We as therapists may begrudge the payment cuts and regulatory burden that CMS enacts, but the reimbursement reductions are crucial for CMS to stay afloat and in business. I totally understand the argument that government leaders may not always have the best business chops, but let’s stick with this premise for a moment.

This is not to say that, when cost reductions impact rehab therapists, specifically, we shouldn’t fight for and defend our profession. But as with any kind of conflict management, there are times when we must assess and pick our battles. In this case, I believe that the recently proposed reduction to PTA and OTA reimbursement may be less rally-worthy than some of CMS’s other payment reduction plans. I know the APTA and other rehab therapy organizations are acting in good faith as they try to organize the opposition camp. It makes sense that they would fight any potential payment reduction that will affect our profession. But I have to ask: is this really where we should focus a large portion of our advocacy attention?

Before you boo me off the stage (or close out of your browser screen) hear me out: I’m not saying that I agree with these cuts or that they’re negligible by any means, but I want to challenge you to take a pragmatic look at this situation. More than that, I want you to widen your lens to consider these cuts in the context of the greater medical community. When you do, you too may wonder whether this fight is worthwhile.

The Situation

For those of you who aren’t in the loop, here’s what’s going on: back in 2018 when Congress repealed the therapy cap, CMS floated the idea of decreasing therapy assistant rates to help maintain a balanced budget. CMS announced its intentions to move ahead with these cuts in the 2019 final rule, declaring that it intended to reduce reimbursement rates by 15% for all services provided “in part or in full” by a PTA or OTA. To manage the billing logistics of this cut, CMS created new payment modifiers: CQ for PTAs and CO for OTAs. Although these lower rates won’t take effect until 2022, PTs and OTs must start using the modifiers in 2020, affixing them to claim lines whenever a PTA or OTA provides more than 10% of a service.

Therapists and therapy organizations are rallying to fight these cuts.

As I mentioned above, many therapists and therapy organizations are unhappy about these payment reductions, and they’re speaking out and making calls for advocacy. The APTA, for example, voiced its disapproval and even created letter templates for providers to send to CMS. The AOTA also denounced the cuts and publicly proclaimed its commitment to advocate against them. The comments from PTs in the APTA’s forums have been especially critical of the proposal, with some PTs calling the cuts “appalling” and others claiming that the art of treatment has turned into a “business machine.” I have even read comments from folks who are involved with policymaking asking, “Who would have thought that CMS would ever cut PTA reimbursement rates?” Really? Is our industry that collectively naive?

The Reality

I understand why the rehab therapy industry is up in arms about these reductions, really, I do. As a former clinic director, I empathize with the clinics that will have to rethink their budgets, schedules, staffing practices, and productivity requirements in order to counterbalance the impact to their cash flow. But, while there’s no doubt in my mind that these cuts will not be beneficial to rehab therapists, I also don’t believe that they have to be detrimental. And honestly, I don’t think they were all that surprising to begin with.

Assistant reductions aren’t new, and they definitely aren’t unique to rehab therapy.

As I mentioned above, CMS floated the idea of reducing therapy assistant reimbursement rates at the beginning of 2018 when the therapy cap was repealed. So, at this point, we’ve known about the reductions for a little more than a year and a half, and we even knew exactly why they were headed our way.

Cutting assistant reimbursement rates is old, old hat to CMS, in fact, similar reductions are pretty standard across the wider healthcare industry. This may come as a surprise, but physician assistants (PAs) and nurse practitioners (NPs) have been reimbursed at 85% of physician rates for more than two full decades. Compliance expert Rick Gawenda, PT, touched on this briefly during his Ascend presentation this year. “In a way, I’m surprised, and in a way, I’m not surprised, that it took our congresspeople this long to figure this out,” he said. And I wholeheartedly second that sentiment. I think we should have seen this coming long before it was announced, and that it’ll be nearly impossible to convince CMS to backtrack.

Therapy assistants aren’t regulated on a national scale, and there’s a lack of objective data that speaks to their value.

We have done our assistants a disservice. We can’t expect CMS to reimburse assistants at the same level as full-fledged therapists when we don’t even have a clear national idea of a PTA or OTA’s scope of practice. Can a PTA provide joint mobilizations? Does a PT need to be in the treatment room to supervise the PTA’s treatments? Well, you better check your state practice act, because these things vary from state to state. We’re going to need to push for some serious regulatory standardization if we want payers, especially a federal payer, to reimburse assistants at the same level as therapists who have met stricter schooling and treatment requirements. I mean absolutely no disrespect to healthcare assistants; they play a vital role in patient care across many specialties. But, health care has a hierarchical standard where payment is commensurate with educational level, and CMS doesn’t have any reason to incentivize leveraging assistants if doing so does not significantly reduce cost or improve quality of care.

PTs and OTs have more training and skills than assistants, and their reimbursements should reflect that.

When it boils down to it, PTs and OTs have received more training and have honed more skills than their PTA and OTA peers, that’s even reflected in their salary differential. A person can become a PTA with a two-year associate degree, while the average DPT will have to complete six to seven years of curriculum before he or she can treat patients. That’s not to say that PTAs and OTAs aren’t knowledgeable, capable rehab therapy professionals; they certainly are, and I know that I have worked with some absolutely amazing assistants during my PT tenure. But, there’s an undeniable gap in education between the two professions. I’d even argue that, in a way, CMS’s willingness to pay PTs and OTs more than assistants is tacit recognition of the time and effort PTs and OTs have put into developing their clinical skillset, and it aligns with what is done in other professions (e.g., physicians and physician assistants).

Therapists still have room to grow their businesses despite these cuts, if they use assistants with purpose.

I want to impress upon you that these payment cuts aren’t necessarily heralds of financial doom and gloom. Clinics will be more than capable of thriving after the implementation of the assistant cuts, without laying off their assistants in droves.

The trick to staying profitable amid these cuts is to look critically at the work PTAs and OTAs are doing in your practice. Logistically speaking, we should be leveraging assistants to improve efficiency and increase patient volume. That means having PTs and OTs administer services that specifically require their specialized skill set, and letting PTAs and OTAs do the rest. Rehab therapists must get out of the mindset that PTs and OTs need to stay with their patients throughout the entirety of the appointment, because that frankly is not always the case. And despite what you may think, sharing a patient with an assistant won’t necessarily take away from the patient’s experience or satisfaction with his or her care.

For example, back when I was a clinic director, we took a deliberate, team-oriented approach to patient care. During a patient’s first appointment, we introduced him or her to the entire team, thus establishing an understanding that the patient’s care would come from a dedicated cohort of people. We made an effort to get buy-in from the patient at the ground level, and it worked out really, really well. Our patients were very satisfied with their care, they achieved stellar outcomes, we could leverage therapists more efficiently, and we were able to use our assistants to their greatest potential. The assistants never hung around, waiting to pick up a therapist’s slack; they followed their own patient treatment schedule and worked with purpose each day. This also freed up time on the therapists’ schedules for more evaluations, and even marketing time. Overall, productivity was measured by the team’s efforts and not by individual contribution.

One caveat: For this approach to work, it’s crucial that everyone on the team, therapists and assistants alike, consistently deliver the same top-notch level of care and practice at the peak of their ability. The patients must know the clear goals and objectives of the treatment plan and believe that there’s no drop in the quality of the care they are receiving, regardless of who’s providing it.

We should focus our advocacy efforts on something truly worthwhile.

Instead of wasting our time and energy fighting what I believe is an almost inevitable reduction, we should focus on wider-reaching (and frankly, more troubling) proposed cuts, like the potential 8% industry-wide reduction that CMS proposed this year. This proposal, which would increase values of certain E/M codes at the expense of non-E/M services (like those typically rendered by rehab therapists), undermines our profession in so many ways, and I truly believe that advocating against it is worth all of the protest that we can muster. That’s especially true considering that over the next two decades, adults over the age of 65 will become the most populous age group in our nation.

Or, how about we all agree that we are experiencing a once-in-a-lifetime opportunity where we can assist with the opioid crisis and monumentally elevate the profession as a whole. If we manage to assert our value in the wider healthcare industry, these reimbursement battles won’t be as difficult to fight, and we may find others who recognize our accomplishments and are willing to fight alongside us. Take a look at primary care and urgent care providers; they need other providers (like PTs) to step up and stem the tidal wave of patients who seek medical help for neuro-musculoskeletal issues.

There’s even a wonderful opportunity in telehealth advocacy. If we lobby for the inclusion of rehab therapists in telehealth payments, the ability to provide remote care could help bring us closer to reaching the 90% of patients who could use our services but don’t ever receive it.

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At the end of the day, once the PTA and OTA cuts go into effect, and I believe they will, there’s not a lot that practice leaders can do to change the payment rates they receive for assistant-provided services. But, clinic leaders can adjust their approach to staffing and appointment scheduling to make up for the rate reduction, and potentially even come out ahead. Now, that’s what I call victory.