Capitol Hill staffers indicate that Congress will most likely address the Medicare therapy caps issue by the end of the year, but aren’t predicting how.
Since 1997, Medicare has capped the amount of Part B therapy services each beneficiary may receive each year. The caps—one for combined speech-language pathology and physical therapy and one for occupational therapy—were designed to control costs, but do not consider a patient’s need for treatment or the provider’s clinical judgment. Every year, Congress has either extended a moratorium on the caps or instituted an exceptions process that allows medically necessary services beyond the cap. Provider and consumer groups, however, are looking for a permanent solution rather than an annual congressional “fix.”
Observers indicate two viable options:
- As the Joint Select Committee on Deficit Reduction formulates its recommendations on debt reduction under the Budget Control Act, larger Medicare legislation, including a new formula for establishing reimbursement rates, could be part of its recommendations. If the “Super Committee” addresses the formula, ASHA, the American Physical Therapy Association (APTA), and the American Occupational Therapy Association (AOTA) will urge committee members to address therapy caps at the same time.
- If the Super Committee does not address Medicare payment issues, observers anticipate Congress will pass a more modest approach—including a possible one-year extension of the current exceptions process.
Caps were never intended as a long-term payment policy. When they were instituted, Congress also called on the Centers for Medicare and Medicaid Services (CMS) to develop a payment system for outpatient therapy services. To date, CMS has provided no recommendations on payment alternatives. ASHA, APTA, and AOTA have formulated a proposal that would create new billing codes for physical and occupational therapy (moving away from time-based codes to per-session codes), refine the therapy cap exceptions process, and repeal the therapy caps in 2015. The three organizations hope the proposal will be adopted as part of larger Medicare reforms, and are working with members of Congress to move it forward.
The yearly moratorium to the caps and the exceptions process indicate lawmakers’ recognition that arbitrary limits on outpatient speech-language, physical therapy, and occupational therapy services are not in the patient’s best interests. However, the cost of repealing the caps and the lack of a viable alternative have forced Congress to maintain the status quo.
ASHA and other stakeholders have worked with CMS for many years to develop an alternative payment system for outpatient therapy. ASHA also worked with CMS and its contractor to develop speech-language pathology-specific questions for a patient assessment tool for the Developing Outpatient Therapy Payment Alternatives project. The tool is in the data collection phase. Given that a new policy is unlikely in the near future, ASHA, APTA, and AOTA will continue to advocate for new payment methodology. ASHA also met separately with CMS in September to discuss health care reform legislation and potential long-term therapy cap alternatives.
Long Term Care Rehabilitation 