Should We Really Fight the PTA and OTA Payment Reduction?

The rehab therapy industry is no stranger to payment cuts—especially at the hands of CMS. But what if we were to look at CMS as a business? Humor me for a moment. CMS focuses intently on remaining budget-neutral, right? Whenever its expenses increase, it must reduce its costs and bring in more revenue. That’s a pretty straightforward business strategy. We as therapists may begrudge the payment cuts and regulatory burden that CMS enacts, but the reimbursement reductions are crucial for CMS to stay afloat and in business. I totally understand the argument that government leaders may not always have the best business chops, but let’s stick with this premise for a moment.

This is not to say that—when cost reductions impact rehab therapists, specifically—we shouldn’t fight for and defend our profession. But as with any kind of conflict management, there are times when we must assess and pick our battles. In this case, I believe that the recently proposed reduction to PTA and OTA reimbursement may be less rally-worthy than some of CMS’s other payment reduction plans. I know the APTA and other rehab therapy organizations are acting in good faith as they try to organize the opposition camp. It makes sense that they would fight any potential payment reduction that will affect our profession. But I have to ask: is this really where we should focus a large portion of our advocacy attention?

Before you boo me off the stage (or close out of your browser screen) hear me out: I’m not saying that I agree with these cuts or that they’re negligible by any means, but I want to challenge you to take a pragmatic look at this situation. More than that, I want you to widen your lens to consider these cuts in the context of the greater medical community. When you do, you too may wonder whether this fight is worthwhile.

The Situation

For those of you who aren’t in the loop, here’s what’s going on: back in 2018 when Congress repealed the therapy cap, CMS floated the idea of decreasing therapy assistant rates to help maintain a balanced budget. CMS announced its intentions to move ahead with these cuts in the 2019 final rule, declaring that it intended to reduce reimbursement rates by 15% for all services provided “in part or in full” by a PTA or OTA. To manage the billing logistics of this cut, CMS created new payment modifiers: CQ for PTAs and CO for OTAs. Although these lower rates won’t take effect until 2022, PTs and OTs must start using the modifiers in 2020, affixing them to claim lines whenever a PTA or OTA provides more than 10% of a service.

Therapists and therapy organizations are rallying to fight these cuts.

As I mentioned above, many therapists and therapy organizations are unhappy about these payment reductions, and they’re speaking out and making calls for advocacy. The APTA, for example, voiced its disapproval and even created letter templates for providers to send to CMS. The AOTA also denounced the cuts and publicly proclaimed its commitment to advocate against them. The comments from PTs in the APTA’s forums have been especially critical of the proposal, with some PTs calling the cuts “appalling” and others claiming that the art of treatment has turned into a “business machine.” I have even read comments from folks who are involved with policymaking asking, “Who would have thought that CMS would ever cut PTA reimbursement rates?” Really? Is our industry that collectively naive?

The Reality

I understand why the rehab therapy industry is up in arms about these reductions—really, I do. As a former clinic director, I empathize with the clinics that will have to rethink their budgets, schedules, staffing practices, and productivity requirements in order to counterbalance the impact to their cash flow. But, while there’s no doubt in my mind that these cuts will not be beneficial to rehab therapists, I also don’t believe that they have to be detrimental. And honestly, I don’t think they were all that surprising to begin with.

Assistant reductions aren’t new—and they definitely aren’t unique to rehab therapy.

As I mentioned above, CMS floated the idea of reducing therapy assistant reimbursement rates at the beginning of 2018 when the therapy cap was repealed. So, at this point, we’ve known about the reductions for a little more than a year and a half—and we even knew exactly why they were headed our way.

Cutting assistant reimbursement rates is old, old hat to CMS—in fact, similar reductions are pretty standard across the wider healthcare industry. This may come as a surprise, but physician assistants (PAs) and nurse practitioners (NPs) have been reimbursed at 85% of physician rates for more than two full decades. Compliance expert Rick Gawenda, PT, touched on this briefly during his Ascend presentation this year. “In a way, I’m surprised—and in a way, I’m not surprised—that it took our congresspeople this long to figure this out,” he said. And I wholeheartedly second that sentiment. I think we should have seen this coming long before it was announced—and that it’ll be nearly impossible to convince CMS to backtrack.

Therapy assistants aren’t regulated on a national scale, and there’s a lack of objective data that speaks to their value.

We have done our assistants a disservice. We can’t expect CMS to reimburse assistants at the same level as full-fledged therapists when we don’t even have a clear national idea of a PTA or OTA’s scope of practice. Can a PTA provide joint mobilizations? Does a PT need to be in the treatment room to supervise the PTA’s treatments? Well, you better check your state practice act, because these things vary from state to state. We’re going to need to push for some serious regulatory standardization if we want payers—especially a federal payer—to reimburse assistants at the same level as therapists who have met stricter schooling and treatment requirements. I mean absolutely no disrespect to healthcare assistants; they play a vital role in patient care across many specialties. But, health care has a hierarchical standard where payment is commensurate with educational level, and CMS doesn’t have any reason to incentivize leveraging assistants if doing so does not significantly reduce cost or improve quality of care.

PTs and OTs have more training and skills than assistants—and their reimbursements should reflect that.

When it boils down to it, PTs and OTs have received more training and have honed more skills than their PTA and OTA peers—that’s even reflected in their salary differential. A person can become a PTA with a two-year associate degree, while the average DPT will have to complete six to seven years of curriculum before he or she can treat patients. That’s not to say that PTAs and OTAs aren’t knowledgeable, capable rehab therapy professionals; they certainly are—and I know that I have worked with some absolutely amazing assistants during my PT tenure. But, there’s an undeniable gap in education between the two professions. I’d even argue that, in a way, CMS’s willingness to pay PTs and OTs more than assistants is tacit recognition of the time and effort PTs and OTs have put into developing their clinical skillset—and it aligns with what is done in other professions (e.g., physicians and physician assistants).

Therapists still have room to grow their businesses despite these cuts—if they use assistants with purpose.

I want to impress upon you that these payment cuts aren’t necessarily heralds of financial doom and gloom. Clinics will be more than capable of thriving after the implementation of the assistant cuts—without laying off their assistants in droves.

The trick to staying profitable amid these cuts is to look critically at the work PTAs and OTAs are doing in your practice. Logistically speaking, we should be leveraging assistants to improve efficiency and increase patient volume. That means having PTs and OTs administer services that specifically require their specialized skill set, and letting PTAs and OTAs do the rest. Rehab therapists must get out of the mindset that PTs and OTs need to stay with their patients throughout the entirety of the appointment, because that frankly is not always the case. And despite what you may think, sharing a patient with an assistant won’t necessarily take away from the patient’s experience or satisfaction with his or her care.

For example, back when I was a clinic director, we took a deliberate, team-oriented approach to patient care. During a patient’s first appointment, we introduced him or her to the entire team, thus establishing an understanding that the patient’s care would come from a dedicated cohort of people. We made an effort to get buy-in from the patient at the ground level, and it worked out really, really well. Our patients were very satisfied with their care, they achieved stellar outcomes, we could leverage therapists more efficiently, and we were able to use our assistants to their greatest potential. The assistants never hung around, waiting to pick up a therapist’s slack; they followed their own patient treatment schedule and worked with purpose each day. This also freed up time on the therapists’ schedules for more evaluations—and even marketing time. Overall, productivity was measured by the team’s efforts and not by individual contribution.

One caveat: For this approach to work, it’s crucial that everyone on the team—therapists and assistants alike—consistently deliver the same top-notch level of care and practice at the peak of their ability. The patients must know the clear goals and objectives of the treatment plan and believe that there’s no drop in the quality of the care they are receiving—regardless of who’s providing it.

We should focus our advocacy efforts on something truly worthwhile.

Instead of wasting our time and energy fighting what I believe is an almost inevitable reduction, we should focus on wider-reaching (and frankly, more troubling) proposed cuts—like the potential 8% industry-wide reduction that CMS proposed this year. This proposal—which would increase values of certain E/M codes at the expense of non-E/M services (like those typically rendered by rehab therapists)—undermines our profession in so many ways, and I truly believe that advocating against it is worth all of the protest that we can muster. That’s especially true considering that over the next two decades, adults over the age of 65 will become the most populous age group in our nation.

Or, how about we all agree that we are experiencing a once-in-a-lifetime opportunity where we can assist with the opioid crisis and monumentally elevate the profession as a whole. If we manage to assert our value in the wider healthcare industry, these reimbursement battles won’t be as difficult to fight—and we may find others who recognize our accomplishments and are willing to fight alongside us. Take a look at primary care and urgent care providers; they need other providers (like PTs) to step up and stem the tidal wave of patients who seek medical help for neuro-musculoskeletal issues.

There’s even a wonderful opportunity in telehealth advocacy. If we lobby for the inclusion of rehab therapists in telehealth payments, the ability to provide remote care could help bring us closer to reaching the 90% of patients who could use our services but don’t ever receive it.

___________

At the end of the day, once the PTA and OTA cuts go into effect—and I believe they will—there’s not a lot that practice leaders can do to change the payment rates they receive for assistant-provided services. But, clinic leaders can adjust their approach to staffing and appointment scheduling to make up for the rate reduction—and potentially even come out ahead. Now, that’s what I call victory.

 

 

About the Author

Heidi Jannenga, PT, DPT, ATC/L, is the president and co-founder of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi leads WebPT’s product vision, company culture, and branding efforts, while advocating for the physical therapy profession on a national scale. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has since guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

An active member of the sports and private practice sections of the APTA, Heidi advocates for independent rehab therapy businesses, speaks as a subject-matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. In 2014, Heidi was appointed to the PT-PAC Board of Trustees. She also serves as a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice rehab therapy professionals.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a lifelong fan of the Aggies. She graduated with a bachelor’s degree in biological sciences and exercise physiology, went on to earn her master’s degree in physical therapy at the Institute of Physical Therapy in St. Augustine, Florida, and obtained her DPT through Evidence in Motion. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.

23 responses to “Should We Really Fight the PTA and OTA Payment Reduction?

  1. Katie says:

    Agreed the assistant cuts are inevitable. I believe the advocacy efforts are specific to the “in part” definition. A PT sees the patient for 90% of the visit and the PTA for 10%. The reduction I’ll apply. That is the current issue… it is a reduction to PT reimbursement as well.

    1. Ali Schoos says:

      That is exactly correct Katie. APTA and PPS are fighting the interpretation by CMS of the law passed by Congress. CMS wants to apply the cut to the entirety of a session if 10% or more of the session is provided by a PTA, AND to any treatment that is given by a PT when the TA is simultaneously included. So, in a 60 min session, of the PTA participates in 6 min of it and the PT does 54 min, the differential is applied to the whole session. If a PT is treating, and calls in the PTA for a second set of hands, so ADDING a practitioner, that portion ( if less then 6 min) is lowered 15%, or if it takes more then 6 min with the PTA there, the whole session could be reduced. So it’s VERY important that not only APTA and PPS fight this, but that all PTs and PTAs fight it.

      1. Agreed that this is a valid and important point. Clearly defined rules without ambiguity is not a strength that CMS has demonstrated thus far. This is what the APTA does best as it should- interpretation, negotiation and lobbying for this clarity. We should all be APTA members to empower our association to do this type of work – another soapbox. But as a profession to rally all PTs and PTAs – we have bigger fish to fry as I mentioned in this piece.

  2. Anna says:

    I will use WBMD again, so dissapointed. This is typical privileged rich male view of the world

  3. Brendon Larsen says:

    The entire comparison between PAs/PTAs is grossly misconstrued. My argument is that PTAs work directly with a PT implementing their plan. This differs from the model used in medicine where Physician Assistants will also complete patient evaluations (as I’m sure you’ve experienced in Primary Care) which merits different reimbursement.

    Second, having an MD on-site or initiating the care creates an exception to the 15% payment differential… which is exactly how the PT/PTA team already operates.

    1. Thanks for your comment Brendon. You seem to be making my argument for me. PAs get paid less and they CAN assess and complete evaluations. PTAs can’t. They are utilized and in my opinion sometimes under utilized to do exactly what you are saying – to implement the PTs plan. I am big fan of the team approach, utilizing each member of that team’s strength to get the best outcome for the patient. Many PTs believe that no one can do that better than themselves – I don’t particularly agree with that. AND the onsite presence of a PT is only required by your state practice act – many states have differing rules – thus my argument of our in justice to have congruency and standardization across our profession.
      We have the opportunity to see more patients in our clinics with the use of the team approach- but the standard of care must be on par. That doesn’t always mean education in the academic sense, but rather in clinical practice and also as we know to be extremely important in outcomes – the customer/patient service levels -the care, the follow through, the outcomes as well as billing. Its about thinking about our clinics as a service business with your patients being your customers and hopefully your raving fans.

  4. Jerry Monaco says:

    I don’t boo you, I APPLAUD you. I agree with utilizing PTAs in a different manner to be an efficient clinic and therefore put all of our efforts behind fighting the 8% cuts.

    1. Thank you Jerry! Appreciate the read and the support.

  5. Jon W. says:

    I appreciate your viewpoint of thinking about CMS as a business, but a couple of points. First Heidi, your argument falls apart when you stated ” For this approach to work, it’s crucial that everyone on the team—therapists and assistants alike—consistently deliver the same top-notch level of care and practice at the peak of their ability.”. In that statement you are admitting that the same level of care is being provided by both the PT and the PTA, so why should we settle for getting less reimbursement for treatment provided with equal skill level? I have heard about this discrepancy in length of education in the past, but keep in mind that 4 of the 6 to 7 years of PT education is for an undergraduate degree with no direct education in physical therapy related care, so in essence it is really two to three years for PT versus 2 years for PTAs of coursework focused on delivering PT care. Second, we cannot ignore any cut in reimbursement, PT is the proverbial frog in the boiling pot where the temperature is increased slowly so that the frog doesn’t realize it is being boiled, that is what is currently happening to us. I think we need to fight aggressively to keep what we get and reverse the trend of continual cuts. If CMS insists on increasing administrative burden and cutting reimbursement at the same time, we should consider examining whether we should accept Medicare patients at all. Thanks for the forum to comment.

    1. Hi Jon – appreciate your thoughtful response. Delivering top-notch care does not mean you have to deliver the same skills. Level of care and practice is about presenting with a patient-first mentality, same philosophy on practice approach, and a customer service level that is consistent. For me it’s not about the skill level and I am not advocating for 4
      more years of academic education. But, the education that is provided to a PTA is specifically for the role – learning anatomy, modalities, ther-ex etc to assist the PT. I do applaud employers like Upstream Rehab who are providing bridge programs for their PTAs who are interested in upskilling to a PT.
      I agree somewhat with the boiling pot – we have had some wins, like Direct Access – but (another topic I have soapboxed about) we haven’t taken advantage of maximizing them to get more notoriety and more clout in the healthcare continuum to push back with a vengeance on issues like the 8% and other major payment cuts. But this isn’t only about Medicare- it would not be positive for us as a profession to not accept Medicare- access to care is already an issue and that would be a disaster. Its about all insurance payment for services – in some areas, Medicare is still one of the best payers.
      I am so thrilled with the comments here – we need more people aware of the issues and willing to advocate for change. Action is always going to be the key!

  6. James D Sparks says:

    I will say you are a “great spin doctor.” Instead of focusing on how much profit they are going to make, how about let’s focus on the patients? All everyone is talking about is how much money these companies are going to keep making, and no one is talking about how it effects the patient’s life, or the therapy assistant’s life? Your answer is have all the PTA’s and COTA’s back to school for 3-4 more years when this country is already drowning in debt incurred by student loans. Then go back to doing what the job they did before, for the same or less pay, at 98.5% productivity. I challenge any other profession to work at 98.5% productivity, especially the law makers.

  7. Paul Leverson says:

    Heidi…
    not to boo you…but here’s some thoughts…

    Value is not established by education. it’s established by what we’re offering. To that end, PTA’s have the ability to offer the same value.

    Salary of each professional is totally independent of the cost of the service. A sweater at JC Penny’s was the same cost to me whether the store manager sold it to me or a teenager.

    Its a definite pattern that government organizations rarely seek to trim their own budgets/personnel/overhead. Instead, they ask the tax payer to sacrifice. What has the CMS done to trim its own sail? Likely nothing.

    PTA’s are extenders, used to create efficiency…profitability…viability. This limits those things based on nothing more than the idea that they went to less school than I did.

    I pay my plumber $65/hour. I pay my mechanic $85/hour. I rest my case.

    My degree means very little compared to my experience and skill. Because I have a degree does not guarantee I’m good at what I do. My devotion to my craft does. CMS has no way to determine that. After establishing minimum standards (which they have already in school/credentialing/national licensing), they should be paying based on the type of skill/service being performed…not who is doing it. Any other way is simply demeaning to the lesser paid clinician.

    Lastly, the CMS is not run like a business in free market economics. There is no competitor. There are not market driven forces to make it be more efficient. It does not create anything. While you could say it offers a service (that being regulation), that’s a long shot. It is a consumer of resources…possibly a necessary one…but a consumer just the same.

    1. Thanks for the comments Paul. I understand your position, but respectfully disagree. I am not arguing that its only about education – its about skill set and licensure. You pay your plumber/mechanic because they are skilled and specialized to do that work – you wouldn’t pay a baker $85 to do plumbing work because it would not be worth it. Your plumber may not work alone and he/she has assistants – he/she is not paying them $85/hr guaranteed.
      I’m disheartened that you would equate PT services to a sweater or a widget – not the same thing in my book as it does matter who is delivering the service in PT- which is why CMS is moving to a value based care model and patient outcomes will and should be considered in payment for services.
      It comes back to our inconsistency of care delivery with no standardization which in many cases is holding us back as a profession. You can go to 5 different PT practices with the same diagnosis and most likely receive 5 different plans of care and treatment plans. That is not how we advance as a profession – its not what the consumer expects or wants. Look at the rise of franchises like The Joint or Massage Envy… like it or not, the consumer expects consistency and a good outcome for a fair price. I’m not advocating for us to become cookie cutter, but I do expect excellent outcomes with some standardization of care across our profession.
      I agree with you that we must tighten the parameters of our skill set as much of what we do today as PTs or PTAs will become automated. We must evolve or become the commodity that you already seem to believe we are.

      1. paul says:

        Hey Heidi…
        Thanks for your feedback. I appreciate your position.

        I’m going to come back to the idea of value. This is not insured by licensure. It is insured by skill set…which is entirely up to the individual delivering the care. To that end, PTA’s have the real possibility of being able to deliver the same value as a PT.

        Despite paying my mechanic $85/hour, he has a tech working on my car. The goal is to repair the car. I’m paying him $85/hour because that’s his garage rate for that service to deliver a repaired car. I don’t ever check with him to see who he has working on it…only that it is repaired. I’m focused on the outcome, not the deliverer of care.

        And I would gladly pay the $85 to have my car repaired. I have never thought of asking the mechanic who worked on my car or how long it took.

        I certainly didn’t mean to dishearten you regarding the sweater metaphor. But again, as a client/consumer, I’m more concerned over the outcome and value of the service, not the deliverer. And, if CMS is really concerned with outcomes and “value based care” they’ll pay attention to the same things.

        Value is what you get. Price is what you pay. ~Buffett.

        I’m all for standardizing care…to a point. You seemed to indicate a similar concern — wishing to avoid “cookie cutter” care. I agree. We made the mistake w/ “evidence based” care to set up all kinds of tracts to put clients in only to find we didn’t have all the evidence but the now accepted care map is established and unforgiving (both by the payor and the clinician). This is an incredible disservice to the client. I’ve seen over the course of my career that it’s impossible to put the care of the person into a certain mold that is unforgiving to their individual needs. Now, even more so with pain science and our knowledge of the complexity of pain. They don’t fit into neat little boxes or protocols. We’re now realizing that principles of care are not the same as protocols of care.

        Lastly, I have a thought in my head…What is more “valuable”? A licensed PT with awesome skills who may be arrogant, a poor listener, and has horrible bed side manner, or a licensed PTA who is compassionate, excellent at building client/clinician alliance, listening to the client and progressing care?

        If payment is dependent on value, then we should pay attention to outcome and soft skills as well as license and hard skills.

        I’d love to get to a point where a client walks into my clinic, reports his complaint he’d like me to address, I evaluate him and then we both sit down and decide on a price for his care. All this without being told by a 3rd party — who’s wholly unvested in the care of the individual — how much my service is worth.

        I’d like to determine how much my service is worth. Better yet, maybe the client should determine that…not CMS.

        Thanks for raising the questions and discussion.

  8. Jd says:

    First off PT’S go to school for 2 maybe three years for their profession. The first four years are for a bachelor’s of there choosing. Mostly none towards any knowledge of physical therapy. The only diffrence between a PT or PTA is that a PT do evaluations and discharges. Most states are starting to let ptas to do joint mobs. Most experienced ptas will have more knowledge than a PT that just graduated. The only reason it’s a doctorate for PT is because the colleges and the physical therapy profession wanted it that way. Plus PT are not doctors.

    1. As I mentioned in my blog, we have done a disservice to our PTAs. And there is ongoing debate about whether or not the DPT was worth it.However, we can’t keep living in the rear view mirrot. Licensure and other policies state there are many more differences between PTs and PTAs.
      Side note -yes PTs are not medical doctors, but we are doctors of PT and we should be very proud of that title – it means something to the consumer and raises our profession to the level of other providers like DCs, DDS etc.

  9. PHIL G says:

    Health care is becoming more and more challenging to navigate in. Medicare cuts will continue to occur.

    1. 8% is all I have to say here – we must come together as a profession to do something about it!

  10. Jill Ludlow says:

    As a PTA and a PTA educator.
    I do agree with her on this. It is going to happen and once it does we will have to figure out how to survive as a profession.

    My argument is this. As a PTA with a small voice in the APTA we rely on PT’s to fight for us. As in the world of healthcare we can’t do anything unless directed by a PT. So we need the PT’s to stick up for us. I can only throw my voice so far, if PT’s don’t pick up and carry on the fight for us I am not sure what the future might hold for me as a PTA. Overall I try to stay positive but sometimes it is hard. Especially as I struggle to place students in clinicals where more and more I am hearing “ we don’t hire PTA’s so we are not interested in taking your student”

    1. Thanks Jill. Completely agree with your comment.

    2. Audrey says:

      I completely agree. Every conversation I have with a PT about this is ‘don’t you get paid less anyway? It won’t matter in the end’. I don’t think PT’s (and especially new DPTs) realize these cuts translate into the elimination of PTAs and them doing more for less. I often hear that we should advocate for ourselves but with a stronger voice from PTs we could prevent this. They can’t see past their own noses that it will inevitably affect their own pay/reimbursement and is irreversible once begun.

  11. Ryan Tournear says:

    We can discuss the niceties and necessities of CMS cuts and split hairs about PT vs PTA education all we like, but at the end of the day it boils down to the vast majority of rehab facilities cannot afford a 15% reimbursement cut and stay in business. CMS is basically eliminating PTA hireability and therefore their viability in the rehab equation. The result being PTs will be expected to perform a greater volume of services than they already do for the same reimbursement. At some point this model becomes impossible to execute given the massive increase in demand for PT that is coming in the not too distant future. It all equates to underserved patients and PTs who will be spread too thin. I’m not sure how these realities can be ignored or rationally debated away. Demand for services will dramatically increase, but rehab companies won’t be able to meet it effectively and stay in business.

    1. Appreciate the comment Ryan. I agree if you maintain status quo, many facilities/clinics will suffer. You add the additional 8% cut on top of that and it may be impossible for some to survive.
      However, it can’t be about status quo. We must evolve and develop new clinical pathways to accommodate for the PTA differential. We still have time to fight back on the 8% and we need to do so with a vengeance never seen before from our profession. You are correct – it equates to decrease access to care in a time when baby boomers will need us and also in combating the opioid crisis -we are the providers to do it!
      We must stand strong and together AND we must get our patients to advocate on our behalf as well – their voices are often much stronger than ours.

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