CMS Presents Reports on Therapy Outpatient Payment Recommendations

ASHA and other therapy organization representatives recently met with the Centers for Medicare and Medicaid Services (CMS) officials and principal AdvanceMed investigator of the Outpatient Rehabilitation Services Payment System Evaluation, Daniel Ciolek. The purpose of the meeting was to discuss AdvanceMed's findings and recommendations for creating a global payment approach for therapy services. The new system would potentially replace the $1500 Medicare financial limitation or cap. However, the research is not scheduled to be completed in time for the December 31, 2005 deadline of the moratorium on the Medicare therapy caps.

The AdvanceMed reports presented five conclusions:

• Speech-language pathology, physical therapy, and occupational therapy are distinctly different services.
  
  
• CMS has the foundation for analyzing outpatient therapy services for policy development purposes.
  
  
• A global approach is the most promising immediate approach to therapy payment policy.
  
  
• Data analysis needs to be supplemented with clinical expertise, clinical and outcomes research, and expert opinion.
  
  
• A new prospective payment system will take several years to develop and implement.

The AdvanceMed global approach would be based on the Medicare physician fee schedule, eliminate the cap, require ongoing data analysis, establish reasonable utilization limitations, rely on national coverage decisions, and use a standardized instrument or three standardized outpatient therapy assessment instruments to describe patient conditions. A first step in establishing the global approach would be the testing of a 21-group clinical classification system. An initial review of the system finds only six of the groups related to speech-language pathology: communication, mental/cognitive, neurological-central, swallowing/feeding disorder, systemic, and general/non-specific impact/other. Conversely, there are nine groups for musculoskeletal disorders alone.

The reports stress the distinction of speech-language pathology services from physical therapy and occupational therapy. Fewer SLP patients were estimated to surpass a three separate cap level than for PT or OT. SLP had the lowest average annual expenditure per enrollee. Moreover, the age distribution of SLP patients increased while it decreased for PT and was relatively constant for OT. SLP services are only 7% of overall utilization for 2002 claims while physical therapy is 75% and occupational therapy is 18%. The reports are posted on the CMS web site at www.cms.hhs.gov/medlearn/therapy/.

The CMS reports will also be used by the General Accountability Office (GAO) in their scheduled report to Congress regarding identification of conditions or diseases that may justify waiver of the therapy caps and to identify criteria for such waivers. ASHA is reviewing the studies and will be submitting comments to CMS and GAO. For more information, please contact Ingrida Lusis, ASHA's Director of Health Care Regulatory Advocacy, at 800-498-2071, ext. 4482, or via e-mail at ilusis@asha.org.