Feedback on alternatives to the therapy cap

Occupational therapy payment restrictions, typically referred to as 'therapy caps' on Medicare Part B, are daily concerns for all occupational therapists working in private practice, outpatient clinics, and nursing facilities. AOTA is participating in a long-term project aimed at finding an alternative to the current cap system. RTI International, the entity that was awarded the government contract to conduct this research, states that "CMS envisions a new method of paying for outpatient therapy services that is based on classifying individual beneficiary’s needs and the effectiveness of therapy services, e.g., diagnostic category, functional status, health status. Currently, CMS cannot evaluate or implement this type of approach because CMS does not currently collect the appropriate data elements."

RTI is proposing assessment tools to describe the characteristics of Medicare Part B clients. The proposed tool for outpatient settings collects demographic data and consists primarily of a patient report of how well they think they are able to participate in tasks. There is a more extensive assessment based on therapist opinion for cognitive, speech, and swallowing functions - no such therapist data is collected for other functional performance areas. It seems that the outpatient tool is potentially very limited - it is rather odd that something as important as determining therapy reimbursement would essentially be dependent on patient opinion of their functional status. The facility-based tool relies more on therapist or professional assessment. For this reason I have fundamental disagreement with the assessment proposal and I don't understand why such different assessment methodologies are in place for the two tools.

I also have some concerns with their data collection and sampling. To begin with, the data collection forms are very long and burdensome - I cannot imagine that many private practitioners will be able to afford to participate because therapists and office staff will not want to wade through so many pages. The outpatient based form is 17 pages long - and when I think about who the Medicare Part B participants are who come into my outpatient clinic I just can't imagine that they are going to want to fill out this long, confusing, small-font form.

The researchers are planning to use a weighting formula during data analysis because of expected frequency and distribution differences between PT (which is a more heavily utilized service) and OT/ST (which are not as heavily utilized). This causes some potential problems with whether or not the OT data will capture the breadth and scope of actual practice. Simple weighting adjustment can really skew data - and weighting only works correctly if you are relatively certain that you have adequately captured a representative sample to begin with. Further confounding this issue is the extreme disparity between the nature of a nursing home Part B population and an outpatient Part B population. I have very little faith that there will be 'enough' correct data in the sample to adequately represent the population of people who come to small private outpatient clinics.

I don't have faith in this data collection tool or the methodology that is proposed for interpreting the data. The outpatient tool is limited to patient perspective on function and is likely to under represent and misrepresent the nature of outpatient Part B OT participation.

I would like AOTA to advocate for a better tool that is based on therapist assessment of patient function (there are already many that already exist) and to advocate for distinct separation between nursing home and outpatient Part B data analysis.

Background reading:

AOTA - Alternatives to the therapy cap update: Need your feedback. Downloaded from on November 12, 2009.


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