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Outcome oriented

By Debra Wood
Monday October 15, 2012


2012 is shaping up to be an important year to vote, with implications for occupational therapists, depending on who controls Congress and who lives in the White House. And much needs to take place before the end of the year or significant cuts in reimbursement will occur.

"AOTA has a broad set of priorities," said Tim Nanof, director of federal affairs at The American Occupational Therapy Association Inc., which remains nonpartisan.

Nanof said AOTA’s regulatory team has focused on ensuring essential health benefits for policies offered through upcoming insurance exchanges created by the Affordable Care Act, and to include occupational therapy as part of the habilitation and rehabilitation services offered. "It was a good thing for occupational therapists that [ACA] passed," Nanof said. "We are supportive of provisions in the bill that relate to occupational therapy, and there were more [positives] than negatives."

Uncertainty may linger

As healthcare facilities and providers continue implementing the ACA and preparing for an influx of patients, the Republican presidential candidate, Mitt Romney, has pledged to work with Congress to repeal the full ACA as quickly as possible after taking office, according to his website. In addition, Speaker of the House John Boehner, R-Ohio, issued a statement after the Supreme Court upheld the ACA that the "ruling underscores the urgency of repealing this harmful law in its entirety."

"Repealing it would not be a good thing for occupational therapy," said Tiffanie Muraoka, OTR/L, OTD, an occupational therapist at California Pacific Medical Center in San Francisco and member of the Professional Development & Leadership Committee of the Occupational Therapy Association of California, citing concerns about consumer protections and access to care.

Meghan Finegan, spokeswoman for the Service Employees International Union, which represents some nursing home- and hospital-based OTs, agreed, stating that SEIU hopes that those elected in November do not repeal the ACA. "We do not want to see 32 million Americans lose coverage or have their insurance protections taken away," she said.

Muraoka said she is worried that under Romney patients needing occupational therapy may not receive it. However, she added the ACA is not perfect. "Romney has not been specific, and my concern is there will be major cuts," she said. "And on the Obama side, I am concerned there is not enough regulation."

However, Tim M. Mullen, OTR, PhD, CHT, director of occupational therapy and business development at Orthopaedic Associates of Michigan in Grand Rapids, and legislative and reimbursement division director at the American Society of Hand Therapists, said the act "requires more for less with greater regulation. It will be difficult to meet the demands. Many hand therapists struggle with the web of regulations required to provide care."

Mullen added that the ACA has the potential to improve access to OT services and increase volume for OTs, but that he remains concerned about whether small practices will survive in the new climate. He anticipates that the ACA "may not always stand as it does, but there will be some form of it that is always with us."

Nanof said he expects Republicans, if elected, would repeal the entire law on political principle, but include some popular provisions, such as coverage for pre-existing conditions and extended coverage for adult children, as part of a replacement platform. According to the Department of Health & Human Services, 3.1 million young adults have gained health insurance because the ACA allows them to stay on their parents’ insurance plan until their 26th birthday, and the Pre-Existing Condition Insurance Plan program, as of February 2012, provides insurance to nearly 50,000 people with high-risk, pre-existing conditions. The plan is a stopgap measure for those denied coverage until the ACA’s prohibition of denying coverage to any American with a pre-existing condition takes effect in 2014.

Desired changes for OTs

AOTA aims to change the home healthcare law to make occupational therapy a qualifying service, which would allow OTs to open and conduct home cases. The House version of the ACA contained such language but the provision did not make it to the Senate bill. The proposed home-health change has bipartisan support, Nanof said. However, he added, "It’s an issue [on which it’s] hard to raise Congress’ consciousness."

Members of AOTA also want to see occupational therapists added to the list of mental health professionals in the National Health Service Corps, which would allow for loan forgiveness for OTs working in underserved areas. Legislation in the House has achieved bipartisan support, Nanof said.

Mullen, at ASHT, voiced concern about the multiple procedure payment reduction, which reduces the practice expense portion of the fee schedule for "always therapy services" for the second and subsequent units provided to the same patient on the same day. He offered as an example when treating someone for 60 minutes and billing four units, the first is paid in full and the subsequent ones reduced. In addition, if the patient sees occupational and physical therapists on the same day, physical therapy may be fully reimbursed for the first unit and then reduced, but occupational therapy will have all codes reimbursed at the lower amount.

"I am not sure the election will have a significant impact except to perhaps delay an unpopular decision until after the election," Mullen said.

Year-end issues

The therapy cap extension comes due at the end of the year. In 1997, Medicare put a limit on the amount of outpatient occupational therapy a beneficiary can receive, and since then, Congress has authorized exceptions. AOTA plans to go back to Congress during the lame duck session to work out another extension to avoid the cap for one year, which will cost $1 billion. A longer-term fix or repeal would be difficult, Nanof said, because Congress would need to find an offset equal to $10 billion for 10 years.

"Historically, the therapy cap has moved in the same piece of legislation as the sustained growth rate fix," Nanof said.

OTs are paid on a fee schedule, as are physicians, and fall under the sustainable growth rate provision. Congress enacted the Balanced Budget Act of 1997, which included the SGR system to set physician and other providers’ reimbursement by Medicare. Since 2003, Congress has passed various bills to override the cuts, according to a report from the Congressional Research Service. But Congress has not replaced the SGR formula or enacted a long-term solution. The current exception is set to expire at year’s end with cuts of 27% scheduled to take effect.

"OTs and other providers are very concerned about this happening," Nanof said. "A cut like that would be unsustainable for practice."

Again, Nanof does not expect a solution, just another temporary fix, because Congress has created such a hole on paper that would be "almost impossible to climb out of with the rules they have established." A one-year fix costs $30 billion and the 10-year permanent correction would cost more than $300 billion. That money would have to be offset by cuts somewhere else.

"Both sides, Democrats and Republicans, agree a 27% cut cannot happen," Nanof said. "There’s not 27% profit in healthcare for most providers. Occupational therapists and physicians would not be able to continue to take Medicare patients."

The failure of the Congressional "Super Committee" to reduce the budget has resulted in a sequestration process, which would result in cuts in all federal departments, including a 2% across-the-board decrease in Medicare payments to providers and an 8.4% cut to special education and school-based programs, where many OTs practice.

"We urge more thoughtful and targeted efforts toward budget reduction and are very concerned about sequestration," Nanof said.

The candidates voters elect in November will likely be left to resolve these issues and others affecting occupational therapy. Muraoka said she encourages OTs, whatever their political persuasion, to advocate for the profession and the patients they serve. •

Debra Wood is a freelance writer.

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By Debra Wood
Monday October 15, 2012
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