Selective use of statistics to support a flawed advocacy position on Medicare therapy cap repeal

This is a recurring theme - what should occupational therapists focus on when they are making decisions about services?  Should they focus on the people that need services, or should they focus on the amount of money being spent?

These ethical choices have been discussed in this blog before.

This question also applies to the latest situation with the repeal of the Medicare therapy cap and the resultant payment differential that has been applied to OTAs.

When attempting to develop an advocacy position - should the occupational therapy profession measure impact in terms of lives affected or in dollars spent?  Here is an analysis of how the professional association is cherry-picking statistics in order to suit their chosen advocacy position.

Perhaps we can call this analysis "A Tale of Two Table Fours"

Here is Table 4 from the Moran Company Report, commissioned by AOTA to look at the Medicare cap issue.

The RED information indicates the numbers of people (beneficiaries) who were receiving OT services.  We will look at the 2015 data.  1,030,580 people were below the therapy cap.  That is 81% of all people who got OT.  Another 174,080 were between the therapy cap and the medical review threshold - meaning they were managed with the exceptions process.  That is an additional 14%.  By these clear statistics, 95% of all people, over 1.2 million people, were not impacted by the caps.  Only 73,760 were impacted by the cap and exceeded the review threshold.

A logical conclusion, based on decision making oriented around numbers of people impacted, is that the therapy caps were not a significant problem for 95% of all people getting OT.

Now we will look at the data a different way.

The GREEN information indicates the amount of money spent on OT services in the same time period.  This chart shows us that 31% of all spending, or $466.4 million was between the therapy cap and the medical review threshold - again meaning this was managed with the exceptions process.  Another $412.6 million was above the medical review threshold, which was 27% of all spending.  In total, that means that 58% of all spending was above the cap, totaling $879 million.

A logical conclusion, based on analysis of this information, is that a very small number of people who receive OT Medicare services are responsible for driving a large percentage of the cost.  

AOTA has had a longstanding policy position of supporting repeal of the Medicare therapy caps.  It is not possible to defend such a position based on the numbers of people impacted, because 95% of them really weren't significantly impacted.  It is much easier to defend the advocacy position when you look at it from the perspective of dollars spent.  That is why AOTA makes this statement:


Here you can see that AOTA reports the data on SPENDING but then makes the deceptive statement that 58% of OT Part B services occurred over the cap.  That is a false statement.  58% of SPENDING occurred over the cap.  That is not the same as 58% of services.

The deception continues.  They say that repeal was needed to preserve access to OT services for beneficiaries.  That is a false statement.  Based on the statistics they are citing, repeal was needed to preserve money. 95% of people had no real threat to access.

As it is not possible to support the advocacy position based on numbers of people impacted, AOTA reports the financial data and then conflates it with the numbers of people impacted.  Those costs are significant, and need to be looked at - but what remains is the ethical matter of whether we are making policy choices based on the needs of people or on the costs within a system.  AOTA chose the latter.

The takeaway of this analysis is

1. 95% of people receiving Med B OT were not significantly impacted by the cap.
2. There were significant cost overruns in the system, primarily driven by a very small number of people whose costs were disproportionate to the number of people within that cohort.
3. A more nuanced policy approach would have been to leave the caps in place and to study the factors associated with cost overruns with a small number of people, and then direct policy to address those findings.

AOTA failed to take the nuanced policy approach, and as a result was able to achieve repeal of the caps but at the cost of a 15% payment reduction for all future services delivered by occupational therapy assistants. 

I am always interested in asking the 'next logical question.'  Here goes.

According to that Moran Report, we know factually that in 2015, beneficiaries receiving outpatient therapy within the SNF made up 73% of all beneficiaries above the cap while also accounting for 74% of total spending above the OT cap.

So why would AOTA take a policy position that is not based on the numbers of people impacted?  Why would they choose to take an advocacy position that is oriented around costs that a very select population of patients were incurring.  Or perhaps, worded differently but meaning the same thing, fees that a select group of long term care entities were billing. 

Could this have anything to do with it?

And it is factual that abusive over-billing is a problem in the long term care industry. 

Is this why SNFs made up 73% of all beneficiaries above the cap while also accounting for 74% of total spending above the OT cap?

Occupational therapists need to decide if they want their membership group to take advocacy positions that serve the greed of long term care companies instead of taking advocacy positions that meet the needs of the largest numbers of people impacted.


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