Part Two: Academic Leadership Council Meeting, October 2017

Part One: Academic Leadership Council Meeting, October 2017 posted here.

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The morning meeting continued following President Lamb's remarks.

Paul Grace from NBCOT followed with a presentation that provided an update on certification issues.  The (ultimate) pass rate for OTR candidates is around 98% and for COTA candidates is around 88%.  The first time pass rate is lower: approximating the mid 80%s to the 90%s with obvious variation from program to program.  There was brief discussion about what states many new certificants are graduating from and where they are seeking their licensing.  None of this information was particularly surprising or new.

NBCOT will be conducting a survey of academic programs to determine what textbooks are most commonly used across curricula.  NBCOT uses this data to serve validation efforts for items that are developed.

NBCOT announced a new policy on 'presumptive denial' of certification eligibility for people who have committed serious offenses.  The policy is here and will be effective in January 2019.  An appeal process exists.

A video was created to educate candidates and the community in general on issues related to cheating on the NBCOT examination.

There were a couple questions - one related to a program's concern about not getting exam results for doctoral candidates who were eligible for the exam, took it, but did not get notification until after graduation.  That will probably be an issue that may need to be administratively hammered out as programs develop new models associated with doctoral level training - so I expect to hear more technicalities like this as systems are developed to cover new requirements.  There was another question about when multiple-selection items would be 'counted' toward exam score - and the answer to that was 2018 now that enough data was collected.  There was another question about the challenges of closing the NBCOT offices for Winter holidays when some students graduate in December.  This sometimes causes short delays until workflow is re-established after holidays.  The audience was reminded that other professions only have open testing windows a few times a year and that efforts are made to process exam results expeditiously.

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The next presentation was given by Sharmila Sandhu, the AOTA Director of Regulatory Affairs.  This was a high-level overview of important policy and reimbursement issues outlining the AOTA perspective on the following:

1. ACA/Triple Aim
2. IMPACT Act
3. MACRA/MIPS
4. Alternative Payment Models

It is far beyond my purpose here to explain what each of these is but I will provide some observation on the tone of the conversations.  In Part One I reviewed President Lamb's comments on how she defined 'value' in occupational therapy services as a function of quality/cost.  I also commented that I am not sure if that is how many practicing therapists define the 'value' of their services.  President Lamb's definitions of 'quality' of OT services are closely aligned with these policies and their associated philosophies.

Unfortunately, 'quality' measures as defined in these initiatives rarely have anything to do with what constitutes most occupational therapy practice in a direct way.  For example, some 'quality' measures might have to do with obesity, or medication adherence, or preventing falls.  All of those issues are of interest to occupational therapists, and in fact many occupational therapists address those issues as part of their larger intervention, but that is quite different than re-defining the 'value' of a profession as part of alignment with those quality indicators.  This is a fine distinction, and it is also a philosophical distinction, but you have to read this paragraph slowly and really think about it.

Re-aligning the value (and purpose) of a profession to meet the quality metrics of CMS might not be what we are supposed to be doing.  However, for people who define our profession based on their understanding of POLICY and not on actual PRACTICE they might not see this distinction.

This is a critical point for practicing therapists to understand, because if you allow people with a POLICY understanding of a profession run the show without adequate checks and balances the profession is left chasing  the whimsical directives of payment systems and not offering services based on people's actual needs.

A quick check on the National Health Service in the UK is an exemplar of the problem associated with allowing the payment source to dictate what is and is not important.  Over there OTs ride around in ambulances to find ways to prevent people from being admitted to the hospital after a fall.  Or they partner with the fire service to make sure people don't smoke in bed.  Those are some fine initiatives but they don't necessarily resonate as 'OT practice' for people who wake up and go to work in the US each day.   This is the kind of philosophical drift that happens when you allow the POLICY makers to start dictating what QUALITY is.  They are defining quality as skin integrity and falls prevention and so on - and that is why OTs are now forced to collect this data and wonder how they are supposed to integrate that into the things they thought they were really supposed to be doing.

I fully understand that some educators and policy-directed OTs are scratching their heads wondering what could possibly be wrong with this, but that is because they don't actually practice and understand how our system is configured and what actual patients need.  They see value-oriented government payment models and think that this is the FUTURE OF OT. 

So in the room at the Academic Leadership Council there was some mix of people who think this is what OT is and should be, and others that don't.  I don't have any sense of the distribution - but the academic/practice divide is a factual element.

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As a final exemplar of the fundamental misunderstanding of POLICY oriented thinkers and academicians, we can look at the current methodology of payment in long term care called the RUG-IV system.  Practicing OTs will recognize this as the system that causes nursing home operators to demand patients be seen 720 minutes each day.  A new system is being proposed - the Resource Classification System (or RCS-1) that will cause a decrease in demand for therapists, promotion of group interventions, and bundling of the OT/PT category.

The audience collectively gasped at the bundling of OT/PT - perhaps because of a deep understanding of the implications on payment but more likely because of the philosophical notion that CMS perceives it as the same service.  There was some discussion about why they would think that, and the speaker oversimplified the response by reporting that the most commonly billed CPT code for both OT and PT is the same code: 97110 (therapeutic exercise). 

Now that is technically correct, but that leads an audience of educators to then say "WHY would we be promoting the use of the same CPT codes that the PTs use?"  It is not a bad question, but it is not a question that is informed by the realities of practice or reimbursement.  The underlying assumption behind the question is that 'those practicing OTs' are intentionally choosing CPT codes based on their non-occupation based treatment, and that is why we have to change CPT codes that have occupation in them because if we did that then people would really understand what OT actually is.  It is a romantic notion but not really an accurate notion.

In a room full of educators the immediate and collective realization during the meeting was that there was a problem with the new Draft Standard B.4.17 - that says:

Demonstrate the ability to safely and effectively deliver therapeutic exercise to address strength, endurance, flexibility, and mobility as a means to promote health, healing, prevent injury, and enhance occupational performance.

Well the thought of many in the room was that we certainly can't have standards that promote therapeutic exercise when that is something that PTs do!  But practitioners should not lose all hope - there was one person who spoke up and understood reality that coding is often done by specially trained people who are not the practitioners, and that the coding is done in some back room based on algorithms generated by savvy administrators and business operators who carefully study reimbursement rates between insurance companies and have figured out how to code for maximum reimbursement.

It is difficult to know if that comment got heard.  I sure noted it.

Many practitioners know that their drop down menus and EHR clicking options are limited precisely because the hospitals want certain codes billed, or they are told that certain amounts of their treatment has to be done addressing certain problems - and that this serves billing.  It generally is not the intentional choice of OT practitioners to bill 97110, except that they are told to do it.

So the end result of this is that educators react to standards based on things that they may only partially understand, and the initiatives and interests of payors influence policy development which is then fed like pablum to the audience that has a mixed understanding.

The solution for this is that the AOTA presenter should have correctly educated the audience on WHY the 97110 code is overused and why that leads CMS down incorrect bundling pathways - and explain that it has little to do with intentional choice of practitioners who are 'not occupation-based' and nearly everything to do with maximizing reimbursement.  Instead the educators in the room were given half an answer that was only partially correct and they ended up wringing their hands over B.4.17.

The other solution to this is to make sure that the people who are elected into leadership positions also demonstrate some balance to their thinking - and to have practice reality added to their policy orientation.

Because we have failed to do that we now have POLICY-directed thinkers who don't practice  promoting a notion that the FUTURE OF OT is skin integrity checks and falls prevention and medication adherence - because it can't possibly be 97110 because THAT is PT!

Watch that standard closely in the next draft.  Practicing clinicians should tell ACOTE to leave it alone, and encourage an advocacy effort to educate CMS to unbundle those OT/PT services in RCS-1.

The OT profession has not really heard about starting such an advocacy effort - but they sure have heard about 'knowing our value' and 'looking to the future' and promoting emerging practice areas like this.  These are the results of policy and academic-oriented solutions that don't reflect the realities of practice.

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Part III will review reaction of the audience to other new draft standards.