By Jeffrey Young - 06/11/08 05:53 PM EDT
Medicare beneficiaries undergoing physical, speech or occupational therapy could see their care disrupted — or start receiving hefty bills — after July 1 if Congress does not prevent it.
On that date, an untold number of patients will learn they have already exceeded the annual cap on their therapy benefits and will have to start paying with their own money or find a hospital that will treat them.
There is widespread support in Congress for preventing this from happening. This week, the Senate began debating competing Democratic and Republican Medicare bills, each of which would rectify this problem. But with time running out, therapy providers say they are preparing to have some tricky conversations with their patients.
“It’s certainly going to be disruptive for patients” if the deadline passes without congressional action, said Paul Precht, the policy director of the Medicare Rights Center. “We’re definitely concerned.”
“It’s a very, very difficult process,” said Peter Clendenin, the executive vice president of the National Association for the Support of Long-Term Care.
Patients undergoing these types of therapy can be in recovery for a wide array of health problems, ranging from strokes to sprained ankles.
According to a CMS-commissioned report from March, 4 million beneficiaries received therapy services in 2006.
Twelve percent of physical therapy patients would have been subject to the cap in 2006, compared to 15.3 percent for occupational therapy patients, 8.8 percent for speech-language pathology patients and 12.6 percent for those who underwent both physical and speech therapy.
Beneficiaries may have been unaware that CMS has been tallying their therapy bills since Jan. 1. Some may have already exceeded the cap and others may be close to the limit. Congress passed a law to protect most beneficiaries from these caps last December, but it expires on July 1.
Patients with relatively minor problems could choose to postpone therapy until Congress acts to extend the protections against the caps. But those with more severe health problems will have tougher decisions to make, including halting their therapy or interrupting their treatment and starting again at a hospital. Those who can afford to can pay the full cost of their therapy from the provider of their choosing.
Under a 1997 law that has never been fully implemented because of subsequent congressional actions, Medicare is supposed to cover only $1,810 per year for physical and speech therapy and $1,810 per year for occupational therapy.
The caps apply to services received in therapists’ offices, physicians’ offices, nursing homes and other settings, but do not apply to therapy received on an outpatient basis at hospitals.
Although patients could opt to switch from their current provider to a hospital, there are not enough therapists available at hospitals to treat them, said Justin Moore, a lobbyist for the American Physical Therapy Association.
About 5,000 hospitals offer outpatient physical therapy, compared to more than 17,000 nursing homes, said Clendenin, who noted that tally does not include therapy at clinics, doctors’ offices and other locations.
Relatively few beneficiaries go to hospitals for their therapy, according to CMS data. “During [calendar year] 2006, the majority of outpatient therapy users received services from non-hospital providers for a number of reasons,” the CMS report states. The facility’s location, the provider’s specialty or the patient’s medical condition typically determine the choice, the report says.
The caps were intended to curb quickly escalating spending on therapy. Medicare spent $4.3 billion on these services in 2004, which was nearly twice the spending in 2000, according to the Medicare Payment Advisory Commission.
Congress has repeatedly stepped in to prevent these from applying to any, or practically any, beneficiaries. In 2006, Congress created a one-year exceptions process CMS can employ to exempt “medically needy” services from the caps. Therapy provider groups say these exceptions have applied to nearly all patients needing treatment. That process was extended for six months in December but expires July 1.