Medicare Payors Reform Act

Hopefully, we’ll all live long enough to worry about Medicare. That being said, would you want an amount of $1810.00 available per year, or an unlimited amount available to you as an elderly, retired person? I am writing from the perspetive of Physical, Occupational, and Speech therapies while discussing this Cap.

Currently Congress has instituted a capitation on Medicare services for participants. They are allowing $1810.00 for PT, OT, and ST PER YEAR. But wait, it gets better. Due to a grammatical error (there was not a comma placed between Speech and Physical Therapy), participants now must share this amount between Speech and Physical Therapy. That’s a whopping $950.00 for each respective service. And let me inform you, as some one who has personally processed the bills, that will get you about 3 treatments if your therapist is conservative and ethical. Don’t blame the Therapists, though….more on that in another article?

Blame is not being placed on anyone, let me stress this. Like most things in life, a little education and understanding can remedy this situation and bring light to all.

On January 6, 2009, 12 senators introduced The Medicare Access to Rehabilitation Services Act (H.R. 43/S.46). This Act will repeal the Capitation on therapy services. The deadline for this act is December 31, 2009, so I implore you to take action now.

Medicare caps were instated in hopes to save money, however, they create unnecessary expense at the health of a patient when they cannot receive full and beneficial treatment. If physical therapists were allowed to see patients for a full recovery, and not rely on some dollar amount to chart their patient’s prgress, this would result in increased patient trust and recovery.

Let me give you an example of what $905 means to a stroke patient. Mr. Jones has had a stroke (date of injury: 1/1/09, full cap available) and he is on Medicare, with no secondary payor. Right away, this leaves him at a 20% disadvantage since Medicare pays 80% of “covered” costs. He calls an ambulance, is hospitalized; upon discharge from the hospital, he has Home Health Physical Therapy. They come to the house and perform therapy services to re-establish his Activities of Daily Living (Medicare will only cover ADL’s). He must then go to Speech Therapy, since the stroke has left him with partial paralysis of facial muscles and he cannot speak well. He then receives Occupational Therapy, which helps him regain a good gait pattern, and the ability to play bridge with his buddies as he has been doing for the past 35 years. The OT’s also instruct him on grooming and feeding. He is doing much better, and now presents to Physical Therapy, where his therapist gives him an appropriate cardiac program, as well as stretching and strengthening exercises to reinforce healing for his hip, gait progress, and basic ADL’s. Mr. Jones has received PT for one month now and he is progressing nicely; however he is not 85% functional which would warrant a discharge. His benefits from Medicare have been exhausted. He decides he will self discharge from PT with a home exercise program, since he cannot afford to pay for treatments out of pocket (conservatively, it would be $85/visit, due in cash at time of service). He does well for two months, however his hip flexors are shortening because he has forgotten to do his Home Exercise Program faithfully. He falls and breaks a hip. As they are wheeling him into emergency surgery for a total hip replacement, he is staring at the ceiling tiles and hoping that this qualifies under the KX modifiers (standards that will allow Medicare to pay above their cap; these modifiers are not a good indication of a patient’s progress). He wonders a bit to himself, wouldn’t it be wonderful if there was not a limit placed on Medicare benefits? If he could have stayed in Physical Therapy and regained all his strength, perhaps he would not have fallen…

We can all make a difference in democracy. Our voices are our future.

I am urging you to contact your senators and your district state representatives and congressional leaders regarding this manner. If they have signed this act, please write them a thank-you note.

I have included links that should be of help, however, this information is readily available online as well.