Eli's Rehab Report

Published on Wed Oct 01, 2008 PDF

Rehab community brings a plethora of concerns to CMS Open Door Forum.

Yearning for the day when the Medicare outpatient therapy caps are no longer plaguing you and your patients? In 18 months, you'll be back at square one with the exceptions process expiring once again.

The good news: CMS hopes to break that pattern by rethinking how it pays for Part B therapy. CMS' Developing Outpatient Therapy Payment Alternatives (DOTPA) project is in the birthing stages of its five-year lifespan -- and now's the time to give your input to CMS and its contractor for the project, RTI International.

Just as CMS is aiming to revamp payment methodology in the Post-Acute Care Payment Reform Demonstration (PAC-PRD), the DOTPA project has similar goals for Part B settings -- to develop case mix adjusters and outcomes measures that support alternative payment models for CMS to consider at the end of the project. Ultimately, project leaders want to see more payment emphasis on patient need and less on setting.

But don't expect CMS to start from scratch. "Our focus is on alternatives for case mix and outcomes that generally fit within the existing system [the Medicare Physician Fee Schedule]", said Edward Drozd, DOTPA project director with RTI, during an Aug. 6 CMS Open Door Forum on the initiative.

What this means: Like with many Part A therapy settings, some aspect of payment would be adjusted based on underlying patient characteristics such as diagnoses, function, cognitive status, etc., which a fine-tuned assessment instrument would collect, Drozd explained. "Right now, we're trying to collect information to see if those or others would be potentially useful case mix adjustors to payment."

Like the PAC-PRD's CARE tool, DOTPA is currently developing a patient assessment tool for data collection. The rehab community has expressed a lot of concern over how this tool will work -- and whether it will support the project's goal of a lesser emphasis on setting.

For one: Multiple participants in the Open Door Forum expressed concern over RTI's proposal to use two separate data collection instruments: one for the non-ambulatory population and one for the ambulatory population (both within outpatient settings).

"By defining your study between ambulatory and non-ambulatory, you have inherently separated it by setting," commented Alan Sauber with national rehab management chain RehabCare. "The group should acknowledge that setting will play a role, and it will impact the methodology you come up with."

Not to mention, patient populations can be diverse within one setting. SNFs, for example, have longtime residents whose primary reason for stay is not therapy, and it also houses people admitted just for short-term rehab, pointed out Bruce Gans, MD, representing the Kessler Institute for Rehabilitation, Select Medical Corporation, and the American Medical Rehabilitation Providers Association.

Reimbursement concern: Dividing ambulatory and non-ambulatory populations could potentially "skew" payment for coverage criteria toward a particular setting, cautioned Christina Metzler with the American Occupational Therapy Association, "and the clinical judgment that therapists apply to these patients is the same across the board."

Another snag: Aside from the arguments about the tool's approach, one can't ignore provider burden. "How are you going to make sure this is a process the clinician can not only do, but do effectively -- especially if it's a paper-based system?" asked Ken Harwood of the American Physical Therapy Association.

Not only does CMS want you to offer feedback as it develops the data collection tool, but it also wants your setting appropriately represented in the study. RTI is looking for roughly 200 providers nationwide, including hospital outpatient departments, private practices, rehab agencies, CORFs, skilled nursing and home health Part B, and other settings where patients receive outpatient therapy services.

"We'll enroll these providers over a one-year period, starting in the second year of our project," Drozd said. Then, the chosen providers would participate for up to six months.

Meanwhile, some good things may happen before the project is even finished. "CMS hopes that the preliminary data collected in this project might support short-term steps taken to address the issues surrounding the therapy caps," said Renee Mentnech, with CMS' Office of Research Development and Information.

Note: You can send your comments about the project to optherapy-comments@rti.org. For more information on the project, go to http://optherapy.rti.org.