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This just in! The MLN called PTs, OTs, STs NPPs
Health Equity codes, PTs, and primary care team growth
Dana Prommel Strauss
February 25, 2024
Hello old friends and new!
Okay, now let me share what I found in a recen CMS Medicare Learning Network (MLN) update (and why it matters)!
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The brief back story on the Health Equity codes added to the Physician Fee Schedule for 2024
CMS is looking for ways to incentivize primary care teams to build capabilities to support patients’ non-medical drivers of health and provide other services that don’t have an accompanying billing code. Until now, if a practice uses resources for Traditional Medicare beneficiaries to do something like identify these drivers and then help solve for them in collaboration with community-based organizations, they are doing it free-of-charge.
One of the new sets of codes are, together, called “Caregiver Training Services.”
From the MLN:
We created new coding to make payment when practitioners train and involve 1 or more caregivers to help patients carry out a treatment plan for certain diseases or illnesses, like dementia. For caregiver training services, we define a “caregiver” as “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”
A snip of the CPT codes used for CTS
AND THEN, it goes on to say this!
Now it’s entirely possible I’m one of a handful of people who noticed something here quite different from CFR 405.400
The addition of these caregiver training codes to the set of new codes for use in primary care is a bigger deal than I think the therapy professions realize. In effect, it positions therapy professionals as part of primary care teams.
While this reference to therapists being NPPs is not in statute, it’s in guidance from CMS.
As a physical therapist myself, a medical professional with a clinical doctorate, it eats at me that we aren’t an integral part of primary care teams. Therapists, please forgive me for saying this, but we have to see the opportunity in front of us and prioritize this for
the good of the professions,
the good of healthcare reform,
and for the good of patients.
PTs have fought for direct access (which we have in all 50 states), have an APTA primary care interest group, and mandated the clinical doctorate as a requirement for licensure. But we have fallen short of being seen as part of the solution to high-value care by the medical community and our largest payer, CMS, and a great lever for gaining some control over astronomical musculoskeletal spend.
Being essentially a cost center in Medicare Part A is one contributing factor. Another is much of the workforce still grandfathered in at the Bachelor’s level. Speaking from my own subjective experience in conversation with therapists who haven’t gone for their DPT and educated and licensed before it was required, they feel largely unprepared for accurate triage and referrals to medical providers in a direct access environment. This is a STARK difference from doctoral-prepared PTs, especially those working in outpatient care.
What I see a lot on social media are therapists in "primary care” on their own. But therapists skipped a step.
Practicing PTs working at the top of license: Join advanced primary care teams with physicians, nurse practitioners, physician assistants, and mental health professionals who are reimbursed through prospective, capitated payments.
WHY?
In advanced primary care teams in full risk, there is no competition for patient visits. Fee-for-service incentivizes providers to fight for face-to-face visit time. When practices are paid prospectively, the incentive for “sick” visits becomes:
Figure out as quickly as possible who the best provider/practitioner is to see the patient first based on their symptoms/complaints. Let that provider/practitioner involve one of the other primary care team members if their evaluation reveals the need.
Let’s not forget the workforce issues this helps solve. It adds another practitioner to the primary care practice to relieve the physician, NP, or PA from seeing patients when the likelihood is the PT can manage them best.
The benefits to patients? Just to highlight a few:
Highest likelihood of getting the most appropriate care as quickly as possible
No need to find outside providers to manage conditions, symptoms, and impairments that the PT can manage themselves or with others on the team
Fewer or no copays in the primary care practice, depending on payer contract rules and regulations
Physical Therapy is High-Value Care:
The American Physical Therapy Association recently published the following, linked here:
And here’s a great video explaining it:
Okay, I’m partially excited about all of this because I KNOW first-hand and through my own skillset that PTs can and should be seeing patients first for many impairments, movement disorders, and many musculoskeletal conditions.
But as a value-based care expert who knows we are a rich treasure-trove of professional resources available to support the move to accountable care, I am excited to be highlighting the opportunity that is HERE NOW.
I propose that the PT profession’s top three priorities should be the following:
Join or collaboratively develop advanced primary care practices that include physicians/NPs/PAs, mental heath professionals, and PTs and be reimburse through full-risk of total cost of care spend arrangements with payers.
Prioritize advocacy for a statutory change to CFR 405.400 and add PTs, OTs, and STs to the practitioner list
Join and influence the conversation about how to reign in high-cost, high-variability musculoskeletal care as first-line practitioners for MSK pain (MSK spend accounts for the highest percentage of healthcare spend in the United States)
Stay tuned for part two of my newsletter about the Medicare Care Choices Model, in your mailbox on Tuesday, 2.27.24!
If you haven’t read part one or want to skim it again, you can find it here!
And if you are interested in AI in Healthcare, here’s a free newsletter I recommend checking out:
Have a great Sunday!
Dana