The following message was sent to AOTA members on February 12, 2018.
Dear AOTA Member,
As you know, last Friday Congress passed a $1.4 trillion budget package to keep the federal government running, increase spending on defense and domestic priorities, and extend multiple health and human services programs. Among these multiple provisions was a permanent fix to the hard cap on Medicare outpatient therapy services that had once again gone into place on January 1, 2018.
However, this massive budget package also included provisions that AOTA did not support. One of these provisions made changes to the way occupational therapy assistants (OTAs) and physical therapist assistants (PTAs) are paid under Medicare Part B. Starting in 2022, after 2 years of data gathering, OTA and PTA services will be paid at 85% of what is paid for services provided by a therapist. This is similar to the current approach to payment for physician assistants (PAs) and nurse practitioners (NPs) who are in general paid 85% of what physicians are paid. AOTA successfully opposed this payment change when it was proposed in the past.
AOTA first learned of these provisions late on the evening of Monday, February 5th, when the House first released this massive bill (just as the Rules Committee began meeting on the bill) which included this provision as a pay-for, among many others. According to Congressional rules, bills that generate new spending must include some “pay-fors.” These are policies that generate revenue or reduce government spending to offset, at least in part, the cost of other policy provisions that require additional revenue. Pay-fors are often kept quiet to prevent advocacy against them.
We were dismayed and concerned by the inclusion of changes to OTA and PTA payments at the last minute; this provision had not been included in previously released discussions or drafts of this budget bill. AOTA had been inquiring about pay-fors for months. Some pay-fors were rumored, but none included the OTA differential. Nor did we hear about the changes to therapy in home health. We did expect some changes to hospital and skilled nursing payments.
After the late-night release of the bill, the following day, Tuesday February 6, while the Senate was still creating its version of the budget package, AOTA reached out to our Congressional champions to oppose these provisions, and, alongside the American Physical Therapy Association, proposed alternatives to the OTA provision—alternatives that would have stopped its adoption or minimized its impact. Additionally, on Tuesday AOTA changed all grassroots advocacy messages related to the repeal of the therapy cap, to include details of the OTA payment changes. AOTA’s position was to ask Congress to first study the issue and its effect on beneficiary access before implementing a change in OTA payment policy. Despite this lobbying, this alternative was not accepted, and the OTA payment changes were included in the final Senate legislation eventually signed by the President.
Repeal of the Medicare outpatient therapy cap was a significant achievement that protects all occupational therapy practitioners providing Medicare Part B services, as well as beneficiaries. Starting on January 1, 2018, all beneficiaries became subject to a hard cap of $2,010 for outpatient occupational therapy services, meaning Medicare would not pay for any services over this cap. In 2015, the last year for which there was data, 58% of occupational therapy Part B services occurred over the cap. This translates to $879,000,000 in claims. Repeal of the therapy cap needed to happen to preserve access to occupational therapy services for Medicare beneficiaries. However, AOTA did not approve of or suggest the payment changes for occupational therapy assistants’ services in exchange for the repeal. AOTA was not consulted about these changes—we opposed them as soon as we were informed, we let our members know they were part of the legislation, and we sought to change them.
With passage of this bill, we can and will continue to fight. Over the next 4 years, the Centers for Medicare & Medicaid Services (CMS) must implement this new OTA policy. Many questions must be answered about the legislative language, which is very confusing. We must also assure data is collected and examined to see whether there are geographic areas (e.g., rural) or settings (e.g., skilled nursing facilities) where beneficiary access to services may be negatively impacted by this shift in payment. We must also reach out to physician assistant and nurse practitioner colleagues to assess the impact the differential has had on them.
We must and will be able to influence the regulatory process through grassroots advocacy, calling on our Congressional champions and leveraging our relationships with CMS. We will make sure policy makers understand there can be unintended consequences from this change and try to narrow CMS’s interpretation of the new law.
Chief Public Affairs Officer
The American Occupational Therapy Association, Inc.
P.S. Please watch for AOTA updates about other provisions, both positive and negative, included in this budget bill, such as the elimination of the use of a therapy threshold in the home health payment method (which AOTA opposed), and on the positive side, extension of the Children’s Health Insurance Program and funding for Federally Qualified Health Centers, which we supported, and for information about a webinar on February 27, at 7:30 pm ET, with AOTA President Amy Lamb and Policy staff.
Read more about changes to Medicare reimbursement for occupational therapy assistants.