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MedPAC is not a direct-access champion

Rehab Regs, March 17, 2005

Commission report isn't physical therapy-friendly, says APTA

Despite lobbying efforts to allow direct access for Medicare beneficiaries, the Medicare Payment Advisory Commission (MedPAC) recommended leaving physician referral mechanisms intact and possibly even strengthening them in the future.

MedPAC submitted its recommendation in a December 30, 2004, report to Congress about the feasibility and advisability of allowing Medicare fee-for-service beneficiaries to have direct access to outpatient PT services and comprehensive rehabilitation facility services.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated this report.

"Beneficiaries often have multiple medical conditions, and physicians can consider their broad medical care needs," states MedPAC in the report. "Without these physician requirements, the medical appropriateness of starting or continuing PT services would be more uncertain."

State-level direct access

The American Physical Therapy Association (APTA) had provided MedPAC with research about the effect of PT utilization in states that allow direct access for their non-Medicare populations. Currently, 39 states allow their residents to forgo a physician referral to receive therapy.

Despite results that showed therapy use didn't increase because of direct access, APTA's research didn't make its way into the final report.

"This is one of the areas where we were a little disappointed," says Dave Mason, vice president of government affairs for APTA in Alexandria, VA.

MedPAC spent more time defending physician referrals than considering the needs of the Medicare population in the report, he says.

MedPAC concluded that the physician referral is necessary to ensure that providers correctly diagnose, refer for treatment, and follow up on Medicare patients' healthcare needs. Its study found that the current requirements do not impair access for most beneficiaries.

"Given many beneficiaries' multiple and chronic health problems, the requirements encourage coordination of the medical care [that] beneficiaries receive," states the report. "Most private payers also restrict their coverage of outpatient physical therapy services, either by requiring physician referrals or setting service limits, or both."

The report also states that although MedPAC found no compelling reason to change Medicare's current requirements for physician referrals and care review, it noted healthcare providers should take other steps to ensure that providing service is appropriate. These steps include the following:

Providers should be more aware of coverage rules for beneficiaries (e.g., through increased educational initiatives by professional associations, claims contractors, and rehab facilities)
Better data are needed about the efficacy of PT for older patients, specifically when and how much the patients benefit from this healthcare service

Other therapy services

The MedPAC report also discussed the effect of direct access for physical therapy on other professions. In addition to physical therapy, Medicare requires physician referrals for home health care, skilled nursing facility stays, durable medical equipment, medical supplies, outpatient drugs, oxygen, and occupational therapy.

The report mentioned a letter that the American Occupational Therapy Association (AOTA) wrote to MedPAC that indicated if AOTA granted direct access to Medicare beneficiaries who needed PT, it would seek the same opportunity for OT.

"The position of AOTA regarding the physician requirements is under consideration," read the report.

"Last year, AOTA noted that there were important public policy reasons to ensure that physicians review the therapy plan of care and attest to a continuing medical need for therapy services," the report said.

Visit to visit MedPAC's Web site at www.medpac.gov to read the report.

Will MedPAC's report prompt congressional action?

The Medicare Payment Advisory Commission's (MedPAC) recommendation on direct access to PT is only that-a recommendation.

Congress may choose to act for or against direct access for PT, but it will most likely sit tight for now.

"The report could be implemented or ignored in part," says Ken Mailly, PT, of Mailly and Inglett Consulting, LLC, in Wayne, NJ . "I think its ultimate impact will be determined by how politically effective the American Physical Therapy Association [APTA] is."

APTA plans to continue advocating for direct access to PT.

"We certainly intend to reintroduce direct access legislation," says Dave Mason, vice president of government affairs for APTA in Alexandria, VA.

"As we've done at the state level, we'll work with members of Congress to gather the evidence on the impact of giving Medicare beneficiaries direct access and building support for the safety and efficacy of eliminating the referral."