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FOTO Rehab Outcomes Blog

The 2018 Medicare Therapy Cap Trickle Effect

Many professional organizations and associations were proactive in addressing a very large problem targeted to go into motion in 2018. Two bills were introduced in February 2017. H.R. 807 Medicare Access to Rehabilitation Services Act of 2017 and S. 253 Medicare Access to Rehabilitation Services Act of 2017. My feelings are very strong about what has happened with these bills.

A simple bill that is only 2-3 pages has sat and sat in either the House or the Senate with no action taken. Sponsors exist (thank you to the supporting sponsors) and each bill was sent to committee. From February until now no action has been taken... nothing! This year the majority of the news I've seen surrounding Capitol Hill has focused on Trump and Russia and North Korea and harassment scandals and health care battles. No one on the Hill has taken the time to prioritize the importance of the Medicare Access to Rehabilitation Services Act of 2017.

When I read up on these bills, the projected prediction of the bill becoming a law is 1-6%. Seems about right for this current year. Nothing has happened since February, so... the population that needs the most advocacy will lose a lot in 2018.

As of right now, in 2018 Medicare beneficiaries will only be allowed $2,010 total to be shared between speech therapy and physical therapy services. Please don't think that this will only affect Medicare beneficiaries. The majority of the patients I treat who have a Medicare Advantage program have the same Medicare rules applied to them.


What does the future for older adults look like with the therapy cap? I can think of a few ideas that immediately pop into my head.

Individuals who have diabetes who need to have an amputation may no longer receive enough services to allow them to safely walk or enter into a building with only stair access.

Individuals who undergo treatments for cancer will not have the opportunity to reach their highest level of function and will experience high levels of fatigue. 

Individuals who have undergone a total knee replacement or total hip replacement (due to their own choice or to trauma) who experience infection or a concurrent complication have a higher chance of being less mobile and at risk of falling.

Individuals who have a stroke, head injury or neurological condition will no longer have access to the required amount of care to help them attain the highest level of function. These individuals will be less mobile and at risk of falling.

Individuals who are at risk of falling may no longer have access to the intensity of care required to change their risk.

Because of reduced mobility, family dynamics will change. Children will need to be more actively engaged in completing household duties parents are no longer able to perform independently.  More and more middle aged adults may need to take time off work to care and support their parents' physical needs. The parents, who are now less mobile, may not be as active in the lives of their grandchildren. Typically this family dynamic change may happen when parents are in their mid to late 80's. Without adequate rehabilitation services, this change may happen when parents are in their 70's. 

We know with older adults that at bare minimum at least twice a week frequency is required to increase strength which improves mobility. We know for older adults that once "frail" happens, it takes 1-2 years to move into a "pre-frail" stage. 

We know older adults have a fixed income. In order for these individuals to afford their care, they will want to use their insurance benefits. This means that these patients will have appointments with physical therapists in a frequency that will not provide the same level of benefit as what science supports. This means that patients will not be able to have the appropriate level of verbal and manual feedback that is required for motor learning/re-learning to happen. Patients may begin having a higher amount of telemedicine services in situations that may not be appropriate. If care is not provided at the right intensity, the right frequency or with enough feedback for appropriate motor learning, the desired outcomes will not happen.

As older adults become less mobile due to limitations in skilled services for their care, these very same adults will become more and more dependent on family members and society. The number of frail older adults will increase. As this happens, the burdens of unhealthy older adults will rise. The cost for hospital services and specialists will rise. Skilled nursing needs will increase ... and as these older adults are drained of their financial assets, then Medicaid comes into play. Although Medicaid is considered a federal program, it is managed by each individual state. Medicaid is funded with both state and federal contributions.

 Although it appears that a financial cap of $2,010 for Medicare to spend on combined speech and physical therapy services for the year 2018 is a cost savings, the trickle down effect limiting access to care to the older adult population actually leads to higher cost. Rehabilitation services account for a small amount of Medicare spending. Rehabilitation services have far less risk than many medical procedures. I honestly can appreciate the concept of a financial cap. I understand money doesn't grow on trees. Rehabilitation services should not be the focus for a financial cap. The high cost, low impact medical interventions, procedures and tests need to be the focus. By not providing adequate payment for rehabilitative care, the long term result is increased cost.

Twenty-six associations or organizations have worked together to persuade legislators to stop the cap. The cap is an arbitrary dollar amount without explanatory justification.  Many health care professionals are taking action to advocate for older adults. This isn't enough. Legislators need to hear from children of older adult parents. Legislators need to hear from older adults. Legislators need to hear from you. Click HERE for an easy way to send your voice to Capitol Hill. Without your voice the projected prediction of the bill becoming a law is 1-6%. 

(image credit: American Physical Therapy Association)


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