June 1, 2000:
The following information reflects recent changes in legislation, policy, and practice since The Physical Therapist's Guide to Health Care was published. Since health care is changing far faster than we can publish a new edition to the book, my intent in providing "updates" is to help the reader and course instructor keep current with developments in the field that influence the practice of physical therapy. If you have questions, information about breaking news, or developments that you feel would be important to share, please communicate with me on this website by clicking "Ask the Author"
President Clinton signed H.R. 2015, the Balanced Budget Act of 1997 on August 5, 1997. This legislation, designed to eliminate the federal deficit, created widespread cuts in the Medicare and Medicaid systems, intended to reduce entitlement spending by $115 billion in Medicare over 5 years and $13.6 billion in Medicaid over 5 years. The bulk of these savings came from reduced Medicare payments to health care providers and hospitals.
Hospitals were slated to lose some $40 billion in Medicare (35% of the overall cuts), while payments to managed care plans under Medicare were to be reduced by $22 billion over 5 years. Further, reductions in hospital payments, home health services, and skilled nursing facility (SNF) payments also reduced reimbursement for physical therapy services.
Physical therapists were especially hard hit by the provisions of the Balanced Budget Act. A synopsis of the provisions of the Balanced Budget Act of 1997 is online at http://www.apta.org/Advocacy/national/national16 There has been, however, some recent good news!
The following updates are important for readers of The Physical Therapist's Guide to Health Care. Further information is available through the links provided.
The Balanced Budget Act included a provision that imposed an arbitrary annual cap of $1500 per beneficiary for services provided by rehabilitation agencies, comprehensive outpatient rehabilitation facilities (CORFs), SNFs and physicians' offices. This legislation also changed the reimbursement system within rehabilitation agencies, CORFs, and SNFs from a reasonable cost basis to a provider fee schedule.
The $1500 cap included an annual reimbursement maximum for the combined costs of physical therapy and speech pathology services provided under Medicare Part B. Occupational therapy services were covered under a separate but similar cap. This extraordinarily low level of reimbursement fell far short of that required to provide necessary services for millions of elderly Americans. The American Physical Therapy Association actively advocated for a moratorium on the $1500 cap until an alternate system could be put into place.
In late 1999, Congress and the White House reached an agreement on a plan to restore more than $12 billion in cuts previously made in Medicare payments. The Balanced Budget Refinement Act eliminated the $1,500 caps on Medicare's coverage of physical therapy, occupational therapy, and speech pathology for 2 years. It also postponed a mandated 15% reduction in payments to home health agencies and increased payments in three rehabilitation categories within the Resource Utilization Groups (RUGs) for skilled nursing facilities (November, 1999).
In late 1999, HCFA also reversed a previous position on student physical therapists in SNFs. Earlier in the year, academic programs placing students in clinical education experiences were thrown into a tailspin when they were informed by skilled nursing facility clinical coordinators that the facility would no longer be reimbursed for services recorded by students in these facilities on the Minimum Data Set (MDS) form.Many skilled nursing facilities anticipated ceasing to provide clinical education programs.
The Trialliance (APTA, AOTA, and ASHA) met with HCFA officials in September 1999 and strongly urged them to change the SNF prospective payment system (PPS) regulations to include rehabilitation minutes provided by students on the MDS. HCFA's reversal of this decision restored the ability of skilled nursing facilities to count minutes of therapy provided by therapy students on the MDS resident assessment instrument of the beneficiary receiving the service.
The Balanced Budget Amendment of 1997 mandated a PPS for SNF care that would pay a federal per-diem rate for SNF services. The per-diem payment would cover routine, ancillary, and capital-related costs. Covered services include all items and services (other than those specifically exempted) for which payment may be made under Part B and which are furnished to an individual who is a resident of a SNF during the period in which the individual is provided covered post-hospital extended care services. This has been implemented since July 1998 with the collection of extensive data about each patient who is hospitalized in subacute facilities. This data is collected and transmitted in the Long-Term Care Minimum Data Set.
Facilities certified to participate in Medicare and/or Medicaid are required to encode and transmit the information contained in the MDS to the state using a format that conforms to standard record layouts and data dictionaries. The state is subsequently required to transmit the data to HCFA using the same standard record layouts and data dictionaries.
This new system of records contains the assessment information (MDS records) for each individual residing in long-term care facilities that are certified to participate in the Medicare and/or Medicaid programs (including private pay individuals). Each state's resident assessment instrument must contain the assessment instrument designated by HCFA, which includes the MDS and its common definitions, triggers, and utilization guidelines.
The LTC MDS includes standard demographic data for identification such as resident name, Social Security number, Medicare number, Medicaid number, gender, race/ethnicity, and birth date. The MDS may also contain data elements that describe the resident's health status in the following areas:
Computerized information about the MDS is available at the following website: http://www.hcfa.gov/medicare/hsqb/mds20
The OASIS is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
The OASIS is a key component of Medicare's partnership with the home care industry to foster and monitor improved home health care outcomes and is proposed to be an integral part of the revised conditions of participation for Medicare-certified home health agencies (HHAs)
A brief synopsis of OASIS requirements for home health agencies is online at: http://www.apta.org/Advocacy/views/view14.
Overall, the OASIS items have utility for outcome monitoring, clinical assessment, care planning, and other internal agency-level applications. OASIS data items encompass sociodemographic, environmental, support system, health status, and functional status attributes of adult (nonmaternity) patients. In addition, selected attributes of health service utilization are included.
In addition to measuring patient outcomes, OASIS data have three important uses in the areas of:
Policy and technical information is available on the OASIS home page at: http://www.hcfa.gov/medicare/hsqb/oasis/oasishmp.htm