Therapy caps a big step closer to extinction

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James M. Berklan
James M. Berklan

Could this really be happening? Medicare Part B therapy caps took a huge leap toward vanishing for good on Thursday. And the reason came from, get this: A bipartisan group of federal lawmakers,

We weren't so sure they made that kind any more. But they apparently do, and long-term care operators, their rehab divisions and the Medicare Part B patients they serve could wind up the big winners.

It was just over a week ago that the American Health Care Association's director of governmental affairs, Clif Porter, sprang it on me that a coalition of providers had reached agreement on how to end the therapy caps. Each year for about a decade, the caps have been trotted out in discussions, teased as a potential target for eradication and then given a rubber-stamp of approval to continue in one form or another, lately with a helpful exceptions process.

So Porter's focus on the caps, which have been around for about 20 years, was a surprise. Yet while he was optimistic, it still seemed more of a provider “wish list” entry. Providers agreeing on something is an accomplishment but hardly reason to stop the presses.

Until Thursday.

That's when Congress officially gave notice it was on the case and engaged. Groups in both the Senate and House stepped forward to endorse a plan to get rid of the caps once and for all. When you have the House Ways and Means, and Energy and Commerce committees and the Senate Finance Committee in the picture, everything gains more color.

"A major breakthrough" is how committee leaders on both sides of the aisle characterized the framework they released on Thursday. A key to recent progress has been a focus on the targeted manual medical review process that many stakeholders say is working well currently.

Participants liken the latest developments to coming up with a permanent Medicare "doc fix” in 2015. If you recall, a misguided policy had guaranteed Medicare physicians exorbitant levels of pay raises, and lawmakers had to scramble annually to stave off their implementation, while also keeping the docs happy.

The ultimate “doc fix” was hailed by all — even long-term care leaders who had to break it to their troops that it would cost them a big pay cut (although one that was not nearly as bad as first feared). In fact, even though it happened two years ago, AHCA leaders still name the elimination of the Sustainable Growth Rate formula (SGR) as a highlight of the current year.

Doing away with the therapy caps would be another good way to take uncertainty out of the picture. Providers crave this type of development. This was brought home again last week by Porter, who spoke fondly of his days as a building administrator but not so glowingly of the uncertainties he and peers had to contend with.

As the son of a guy who had a devastating stroke, I can also personally attest that patients and their families would be thrilled to know that under the proposals, a) therapies wouldn't be restricted by some arbitrary barrier and b) speech and physical therapy wouldn't be grouped together under one limit. Stroke survivors are hit particularly hard by the latter.

The annual caps are currently $1,980 for occupational therapy, and $1,980 for speech and physical therapy together. Claims above those levels are marked with a modifier, a variation of which would still remain, according to House lawmakers. Under the proposal, targeted manual medical reviews for claims over $3,000 would take place. The current threshold is $3,700.

Leaders of AHCA and the National Association for the Support of Long-Term Care (NASL), were among the execs applauding Thursday. According to the AHCA, nearly 900,000 Medicare beneficiaries received Part B therapy services from a skilled nursing provider in 2015.

As Porter pointed out last week, however, the cost of the new proposals is not known. There is no official scoring — or cost projection — yet. The “cheddar” to pay for them needs to come from somewhere, so that could still be a major stumbling block.

Look for significant developments over the next few months. This is another "fix" providers would love to see themselves out of by the end of the year. They're going to do everything they can to make it happen.

Follow McKnight's Editor James M. Berklan @JimBerklan.

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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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