A Stocking Stuffed With Questions Legislative Inaction On Medicare Cap Angers Physical Therapy Advocates

The failure of the U.S. Congress to repeal a $1,500 cap on Medicare rehabilitation services before adjourning for the holidays has angered the American Physical Therapy Assoc., along with other physical therapy advocates.

“Now that Congress has adjourned, Medicare enrollees are faced with the harsh reality that their rehabilitation benefits will be arbitrarily reduced in 2003,” said APTA President Ben F. Massey Jr. “With more Medicare cuts to come, that’s not a lot to be thankful for.”

Massey spoke specifically of the Medicare Access to Rehabilitation Services Act, which was introduced in the Senate by Sen. John Ensign (R-NV) in September 2001, and in the House of Representatives in February 2002 by four legislators. The legislation is designed to repeal the $1,500 cap on outpatient therapy services originally imposed by the Balanced Budget Act of 1997.

The cap briefly took effect in 1999, but a moratorium placed upon it that year was set to expire on Dec. 31, 2002. The proposed legislation would have prevented the cap from taking effect in the new year.

An Ill-fitting Cap

APTA, a professional organization representing nearly 64,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide, argues against the cap on several fronts.

First off, the organization claims, the $1,500 cap discriminates against the frailest Medicare beneficiaries — those who suffer from strokes, hip fractures, Parkinson’s disease, or other conditions that require extensive rehabilitation.

According to the American Speech-Language-Hearing Association (ASHA), another therapy advocacy organization, in the two months in 1999 when the cap was in place, 43{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of those who exceeded the cap for speech-language pathology and physical therapy suffered from stroke- and heart-related circulatory ailments, and 28{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} suffered from osteo-arthritis or related musculoskeletal disorders. The percentages were similar for those who exceeded the cap for occupational therapy.

“It is clear that the caps achieve no real cost savings and only serve to deny care to the patients who are in the most critical need,” said Reed Frnklin, a spokesman for ASHA. “Rather than simply extending the moratorium on a year-to-year basis, Congress should repeal the caps outright.”

Most beneficiaries would never exceed the $1,500 cap, APTA admits. However, it would force about 13{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of seniors and individuals with disabilities to pay for therapy services out of pocket.

Furthermore, concerns over the cap’s impact have already been recognized by Congress on numerous occasions, its detractors note. Twice legislators have imposed a moratorium on enforcement of the cap after hearing the arguments of beneficiaries and health care professionals. In 1999, Congress instituted a two-year moratorium, and that was extended in 2000 for another year, ending on Dec. 31 of 2002.

APTA argues that absolute dollar limits on outpatient rehabilitation services are unnecessary. The reason is that all such services are now being reimbursed pursuant to a fee schedule based on the Resource Based Relative Value System for physicians. The move from cost reimbursement to a fee schedule, the organization claims, does away with the need for a fixed dollar limit on beneficiary services.

“The $1,500 caps are arbitrary and have a negative effect on the ability of physical therapists to deliver care to patients in a rational manner,” Massey said. “Furthermore, they bear no relation to the medical condition of the patient nor to the health outcomes of the services.”

Further Inaction

In addition to failing to address the therapy cap issue, Massey said, Congress also adjourned for the session without correcting the physician fee schedule, restoring payment reductions for skilled nursing facilities or home health agencies, or increasing payment to rural health providers, all of which actions APTA supported.

“Congressional leaders and the White House haven’t been able to agree on a reasonable Medicare package, even though there is strong bipartisan support for such issues as the moratorium on the therapy cap,” Massey said. “The legislative process has failed badly in this case, and it’s very disappointing.”

The group promises, however, to work for passage of a bill lifting the cap early in the next Congress, which convenes in January.