Guest Columns

It's that time of year again ...

Tara Roberts
Tara Roberts

No, I'm not talking about the holidays. This time of year means, once again, it is Therapy Cap Repeal discussion time.

Currently, we should understand Medicare Part B through the lens of Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). That extended the therapy caps exceptions process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps.” 

The therapy caps amounts are determined on a calendar year, so beneficiaries begin each year with a new cap. To commemorate the 20th year for a therapy cap limit on patients' therapy, I thought I would share 20 reasons why the caps should once and for all be repealed.

  1. Consider whether the reason the therapy cap exceptions is always extended is because the therapy cap isn't meaningful.

  2. The therapy cap is arbitrary with no relative historical or statistical support. There's no reason for physical therapy and speech language therapy to share this cap and occupational therapy to have its own cap.

  3. The therapy cap robs beneficiaries of the services they need. The $1,980 per Medicare beneficiary per year cap makes no distinction between beneficiary needs thus does not consider how much therapy may be required. The beneficiary with the greatest needs thus requiring more therapy are forced to jump through hoops of required medical review.  These hoops are designed to discourage additional therapy. The impact is that those that need therapy the most have to justify it the most.  

  4. The therapy cap ties the hands of skilled licensed practitioners to respond to beneficiary changes in conditions fully and responsibly.

  5. The therapy cap limitation is counter to the current quality initiatives and Triple Aim.

  6. It limits the potential impact of therapy services to reduce unnecessary re-hospitalizations specifically for the long-term care beneficiary.

  7. It limits the potential impact of therapy services to increase successful and responsible discharges.

  8. It limits the potential impact of therapy services to significantly improve the patient experience of care through proactive, preventive responsible therapy interventions-dimension one of the Triple Aim.

  9. It limits the potential impact of therapy services to significantly improve the health of populations through disease management education, early interventions and specialized services-dimension two of the Triple Aim.

  10. It limits the potential impact of therapy services to reduce the per capita cost of healthcare through once again disease management education, early/proactive interventions, specialized services, unnecessary re-hospitalization mitigation and successful discharge to the community-dimension three of the Triple Aim.

  11. The therapy cap fails to appropriately recognize the unique and necessary benefits of all three skilled therapy services.

  12. The therapy cap fails to recognize the indisputable differences in therapy needs of the long-term care beneficiary, including the challenges of disease management and the impact of their chronic conditions and complexity of comorbidities on their well-being.

  13. One would think we are better than arbitrary therapy caps that are designed to limit much needed skilled therapy services for the pursuit of quality, value and sustainable outcomes.

  14. The therapy cap discriminates against specialized therapy services that are valuable to a beneficiary's recovery and well-being. That includes physicial therapists and advanced wound healing, occupational therapists for caregiver education and beneficiary management throughout the dementia progression, or SLPs, who specialize in stroke recovery for swallowing and cognitive recovery.

  15. The cap is a barrier to F-Tag 406 compliance:  Provision of Services.The intent of this regulation is to assure that residents receive necessary specialized rehabilitative services as determined by the comprehensive assessment

  16. It is a barrier to F-Tag 309 compliance: Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

  17. The therapy cap is a barrier to F-Tag 314 compliance. Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and a resident who has a pressure ulcer receives care and services to promote healing and prevent additional ulcers.

  18. A therapy cap is not necessary given a very aggressive CMS auditing agenda that validates skilled nursing and therapy services.

  19. The therapy cap needs to be repealed because it's the right thing to do for Medicare beneficiaries and maintaining access to skilled therapy services.

  20. And finally, repealing the therapy cap once and for all actually frees up much needed time and resources to be dedicated to the Triple Aim and Quality agenda that we ALL can agree on instead of beating a dead horse year after year after year!

Let's make this a very special and memorable 20th anniversary.  In the spirit of reforming healthcare and reimbursement and the Triple AIM, put the therapy cap out of its misery!

Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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