Drive to repeal therapy caps gains supporters

More than 200 lawmakers have joined a rank-and-file campaign to pressure their leadership and the Medicare agency to undo permanently an almost 10-year-old policy of strict limitations on physical, occupational and speech-therapy services.

Nursing homes and other healthcare providers are driving the effort by passing along tales of woe about senior citizens and disabled people who have postponed needed therapy out of fear of hitting the cap.

Neither the Centers for Medicare and Medicaid Services (CMS) nor congressional aides could quantify how many Medicare beneficiaries are at risk of being denied healthcare services this year. Nevertheless, lobbyists for healthcare providers have pushed for elimination of the cap every year since it was created as part of the Balanced Budget Act of 1997. Congress and CMS have acted numerous times to prevent the caps from taking effect.

Despite a general sense of reluctance among congressional leaders to address any Medicare issues this year amid political jockeying about the controversial new Part D drug benefit, there is a strong likelihood that Congress will take up legislation addressing the therapy cap.

At the beginning of the year, a law took effect that restricts Medicare beneficiaries to $1,740 in physical and speech therapy and $1,740 in occupational therapy.

The Deficit Reduction Act, signed by President Bush in February, required CMS to create an “exceptions process” to safeguard beneficiaries with the highest need for therapy from being summarily cut off.

The exceptions process is widely regarded as broad enough to apply to nearly all Medicare beneficiaries who might need extensive rehabilitation therapy. Patients recovering from stroke, brain surgery, joint replacements or serious injuries make up some of the most expensive cases. The CMS policy establishes automatic exceptions for certain types of patients. Other beneficiaries, and their healthcare providers, must apply for exceptions, however.

But the law only authorized the exceptions process for one year, meaning beneficiaries and therapy providers will stare down those hard caps again beginning Jan. 1, 2007, if Congress fails to act.

The short-term goal is to renew the authorization of the exceptions process for one year.

Late last month, Rep. Phil English (R-Pa.) and 176 House members sent a letter urging action on the therapy caps to Ways and Means Committee Chairman Bill Thomas (R-Calif.), Energy and Commerce Committee Chairman Joe Barton (R-Texas) and their respective health subcommittee chairs. Sen. John Ensign (R-Nev.) and 46 colleagues sent a similar letter to Finance Committee Chairman Chuck Grassley (R-Iowa).

“Without Congressional action in 2006, the arbitrary therapy caps will return on January 1, 2007 and will result in restricted access to rehabilitation services and a shift in patients and costs to inpatient settings” such as hospitals, English wrote.

English and Ensign also sponsored bills to repeal the caps permanently. The House bill has 251 co-sponsors, including Majority Leader John Boehner (R-Ohio) and Majority Whip Roy Blunt (R-Mo.). The Senate bill has 44 co-sponsors.

Grassley backs a one-year extension of the exceptions process, according to a spokeswoman. The Finance Committee’s mark of the Deficit Reduction Act included a full one-year moratorium on the cap, which the Congressional Budget Office estimated would have cost $530 million for fiscal year 2006.

Congress and Medicare have been facing off over this issue for years, and the matter is not likely to be resolved before lawmakers move to again postpone establishing a permanent policy regarding the therapy benefits.

Congress put the cap in place in response to skyrocketing Medicare spending on therapy services. Lawmakers and the Medicare agency did not understand why the program was spending so much more on therapy than it had in the past.

Congress intended the cap to serve as a temporary solution while the agency analyzed why spending was rising at a rapid rate and proposed a permanent policy that balanced the needs of patients who need therapy with the need to control Medicare spending.