Monday, January 30, 2006

Medicare limiting therapy payments

Aside from Medicare drug benefits in shambles, the Medicare therapy caps are also causing problems for senior citizens. It essentially means they cannot go to therapy clinics after a set amount of visits even if they are still suffering. The Congress-approved Medicare system will not allow them to come back to therapy clinics despite the fact that the treatment is not complete.

Read more below..

Source: Lindy Washburn / North Jersey Media Group Inc.


Overshadowed by the furor over Medicare's new prescription drug plan, another change in Medicare benefits took place on Jan. 1 that could have a serious impact on stroke victims and others who need rehabilitation therapy.

A limit of $1,740 will be imposed this year on physical therapy and speech therapy services. Another $1,740 limit will be imposed on occupational therapy services, which include adaptations such as brighter lights, grab bars or stair lifts to make the activities of daily life easier.

The caps apply to care received at free-standing practices, not at hospital-affiliated centers or nursing homes. Originally imposed as part of the 1997 budget-balancing act to cut Medicare costs, the caps have been delayed three times by Congress. The most recent moratorium lapsed on Dec. 31.

"It makes a huge difference to me," said Tobi Goldstein, 72, of Little Falls, who has Parkinson's disease.

Without physical therapy, "I would probably be in a wheelchair," she said. "I thought I would have to go into some sort of facility with assistance, whereas now I can live in my own apartment."

Goldstein says there is no way she can pay for her twice-weekly sessions at Suburban Physical Therapy in Cedar Grove. "Without them, I can tell you: Very, very quickly my condition will deteriorate," she said. "It took such a long time to reach this point. It would be such a pity to plateau and go downhill."

Few patients have hit the limits yet. But active seniors - who might injure themselves twice in one year, or recover from a fall and then have joint surgery - are also concerned, said Matthew Riordan, a physical therapist at Suburban. Others, such as stroke patients, rely upon therapy to learn to walk and swallow again. The caps essentially limit them to about 12 physical therapy sessions.

Once coverage runs out, they must pay their own way, switch to a hospital-based center or do without.

"We're dealing with the most frail patients," sad Richard Stoneking, president of the American Physical Therapy Association in New Jersey. "The problem will escalate as the year goes forward. ... Then people will ask, do I forgo necessary care or do I pay out of pocket?"

About 3.7 million people, or 9 percent of Medicare beneficiaries, receive one or more types of outpatient therapy a year, according to the Government Accounting Office. The services are covered under Medicare Part B, if necessary to improve a patient's condition.

Congress has long struggled to control spending on Medicare outpatient therapy, which grew at double the rate of overall Medicare spending in the early 1990s. In 1997, it adopted caps on the payments for services.

"Every Medicare beneficiary should care about this," said Dave Mason, vice president for governmental affairs of the American Physical Therapy Association. Even a relatively healthy person might encounter a problem early in the year that eats into his cap, and then not have enough later in the year to pay for therapy services after surgery or a stroke, for example.

Rep. Frank Pallone, D-Monmouth, has introduced a measure to repeal the Medicare therapy caps. "I've always supported eliminating the caps," said Pallone, the senior Democrat on the House of Representatives health committee. "A lot of people who are impacted by them can't pay out of pocket."

So far, 241 House members - a majority - have endorsed his bill, "The Medicare Access to Rehabilitation Services Act of 2005." It also has the support of 41 senators.

"The reason caps don't make sense," Pallone said, "is that they're not based on what's medically necessary. ... It's just budget driven."

Conference committee members on this year's budget reconciliation bill took a different approach, however. They recommended that the caps remain, with exceptions granted for medical necessity by the secretary of Health and Human Services. The House is likely to take up that modification when the next session begins on Jan. 31.

Physical therapists have urged the director of the Centers for Medicare and Medicaid Services to allow exceptions to the caps while the issue is pending in Congress.

The American Occupational Therapy Association is looking "forward to working with Congress in the next year in order to provide a more permanent solution for the cap problem," said its spokesman, Rob Black.

If the caps had been in place in 2002, last year's GAO report found, about a quarter of Medicare's payments for outpatient therapy, or about $800 million, would not have been paid unless an exception had been granted.

What it means

What's new: Medicare patients are limited to $1,740 for physical and speech therapy services at free-standing centers. There is another $1,740 limit for occupational therapy.

What's next: U.S. Rep. Frank Pallone, D-Monmouth, has introduced a measure to repeal the caps. A majority of House members has endorsed the bill.

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