The other day, I became part of a conversation that made me feel like a character in one of my old favorite TV shows-Outer Limits.  The conversation was about medicare G codes and when you must change them, conditions for when you must charge a re-eval, and umpteen  reminders of what triggers claim rejection (like most providers tons of claims have been getting kicked back).  It also eerily reminded me of the years of listserve debates over what scenarios constitutes Group Therapy in medicare (remember my old published quiz?).  Professionally, I would much rather see PT’s talking about patient care issues rather than spend obscene hours on medicare claims, rules, edits, and regulations but that is the environment that we live in.  I have written extensively about our good friends at Medpac (here is a consolidated partial listing) and have concluded that they would eliminate physical therapy as a benefit if they had the powers but since they don’t, they will  accomplish the same end game by regulating us out of existence.

I think most folks including medicare beneficiaries would say that their insurance has a physical therapy benefit.  I would put forth the question, when does a benefit seek to being a benefit?  Turning to private insurance plans for illustration, it is a legitimate question-one that frankly helped us get passage of copay legislation in Kentucky (complete run down here).  We are all familiar with plans that pay $65 per visit with a $55 copay. Said differently the insurance benefit is paying $10.  If providers opt out (strongly recommended) and the patient and/or employer  is paying their premium, does a patient really have a benefit if they bear essentially all of the cost?

Back to medicare.  Rough numbers. Total Medicare expenditures are well over 500 billion. Medicare beneficiaries or patients number about 50 million.  Medpac’s data shows that roughly 15% of medicare patients access outpatient rehab (combo of PT, OT, SP) at a cost of roughly 5 billion (yes, we are about 1% of total medicare). Medpac’s data show that roughly $1200 per medicare patient that accesses rehab services and this does not include patients 20% or deductible which can be lessened by supplemental insurance.

Here is a rough checklist of the benefits, implications (realities), and requirements for providers who likewise enroll in the onerous process for accepting medicare patients:

Plan of Care mandate

Extensive documentation requirements

Protracted training in all of medicare rules and regulations

PQRS

G codes-what, when, where, how (all of which is still up in the air subject to random interpretation)

8 minute rule (what PT clinic doesn’t have a chart with breakdown of 8 minutes and allowed units to bill?)

Medicare technical compliance (Arbitrary filing, MD signature, and  plan of care days)

Red flag alerts for going over cap amounts

Exceptions process

Goals in pseudo functional terms to wordy and flowery to make clinical sense

Stringent requirements that do not allow support personnel to share same oxygen with patient (regardless of your state’s practice act)

Disruptive scheduling process to avoid or risk medicare patient overlaps

Medicare audit-fears

Whistleblower fears

Fraud and abuse fears

MPPR effect and 15% real reimbursement reduction over last 3 years

ABN forms for items that have evidence but are not covered

Uncomfortable conversations with patients about ABN

Participation in chart reviews and internal audits

Over abundance of time spent on medicare training (have to mention it twice)

Inability to opt out of Medicare

Benefit to Medicare Patients:

Scared, disengaged PT who really doesn’t want to see medicare patients

PT who spends more time with EMR or paper than with patient (estimates of over 30% of patient “care” time)

Deductible and confusion over medigap coverage

Non covered items that have evidence

Inability to opt out and pay cash to see cash based practice

My solution is very simple. Let’s ration #physicaltherapy in outpatient Medicare.  Pick a percent such as 1% of the total Medicare expenditures (side note-in group health PT is a much higher percent). Using 2012 figures and the number of medicare patients that access PT, have medicare pay $1200 as a max payment AFTER a patient has paid $300 in a #physicaltherapy deductible (this factors in their current 20% and overall out of pocket expense due to annual deductible).  If a patient goes past the $1200 a supplemental policy or out of pocket must kick in.  An argument can be made that the number could be more like $1800 because CMS can cut all their auditing and regulatory costs of administering physical therapy under its current processes.  Providers would still have to have an NPI number and go through credentialing but would not be subject to the ridiculous amount of paperwork, disruptive constraints, and superimposed rules.  The extraordinary time spent on non patient care can be replaced with more time spent with the patient!  The consequence would of course be that physical therapy would become a real benefit to medicare patients.

Thoughts?

@physicaltherapy