Therapy cap could affect your bottom line

Congress may repeal $1,500 limit

The proposed $1,500 cap on Medicare reimbursement for outpatient therapy services could have dire effects on the elderly rehab population and force rehab providers to change the way they practice, outpatient providers say.

Unless it’s postponed or repealed by Congress, the proposal, part of the Balanced Budget Act of 1997, is scheduled to go into effect Jan. 1, 1999. It sets a $1,500 annual limit per patient on reimbursement for physical therapy and speech therapy combined and an additional $1,500 limit on occupational therapy services provided at freestanding outpatient clinics and comprehensive outpatient rehabilitation facilities (CORFs). Outpatient clinics within rehab or acute care hospitals are not affected by the limits.

If the therapy caps go into effect, there could be dire results for elderly patients in the rural Penn sylvania areas served by Riverside Rehabilitation Center in Plains, PA, says Frank Pugliese, CHE, chief executive officer. Riverside is an outpatient provider that treats primarily elderly patients at two CORFs and five satellite clinics.

Many rehab patients in rural areas are served by freestanding outpatient providers in their communities and would be subject to the $1,500 cap. To continue to receive treatment when they reach the cap, residents of the rural areas would have to travel long distances to hospital outpatient departments. For example, Riverside Rehabilitation Hospital now provides outpatient services in rural Monroe County. If those patients exceed the $1,500 cap, they will have to make an 80-mile round-trip to the nearest acute rehab center for therapy.

"The choices of rural patients are going to be extremely limited," Pugliese says. "The quality of care will be affected in many areas just by the logistics for treatment patients and the coordination of benefits."

When patients shift to another outpatient treatment center in an acute rehab hospital, staff are likely to do their own assessments and evaluations before beginning treatment, which will add to the total cost of rehab, he points out.

To make adjustments, Riverside will change its focus from Medicare patients to those whose care is reimbursed by other payers, such as workers’ compensation and managed care plans. Pugliese is considering sports medicine, chronic pain, pediatric, and work-hardening programs to make up for the loss in Medicare patients.

As the number of visits become limited, outpatient providers will focus on teaching home exercise programs and helping patients learn what equipment they can use in fitness centers to continue with their rehabilitation after their benefits run out, predicts Agnete Mansori, national clinical director for outpatient services at Progressive Steps Rehab in Milwaukee.

"In the past, we provided treatment and made patients dependent on us in outpatient services," Mansori says. "Part of my job is teaching clinicians to let go of patients, to teach them to be independent, and to rely on patients and caregivers to learn what to do away from the clinic."

Outpatient providers must embrace the concept of educating patients to take care of themselves and handle their impairments, she says. At Progressive Steps, staff are looking at ways to make each session of therapy more intensive. A therapy session eventually may serve as a teaching session to help patients learn what to do at home to make a difference in the long run.

"Once they get over the acute stage, most people should be able to continue on their own with a monthly or biweekly checkup with the therapist, rather than coming in three times a week," she says.