Two Steps Forward...

Paula Span of the New York Times did the geriatric community a great service this past week by highlighting a change in coverage for physical therapy services. It's a change that hasn't gotten much press because it sounds pretty technical, but it has enormous ramifications for older or disabled patients undergoing rehab. For many years, Medicare insisted it would not pay for physical therapy unless a patient was getting better. Once a patient had “reached a plateau,” reimbursement would cease. In a class action suit settled in 2013, Jimmo v Sibelius, the Centers for Medicare and Medicaid Services was advised that the statutory requirement that Medicare pay for physical therapy services that are “reasonable and necessary to prevent or slow deterioration” did not support the “improvement standard" CMS has been using to implement the law. Bottom line: CMS needs to change its approach. It was instructed to embark on an educational campaign to clarify the correct policy and to modify its “Medicare Benefit Policy Manual” to reflect the court’s interpretation. According to a ruling by a US District Court in Vermont, CMS has modified its manual but fallen short in the education realm.

I’m a geriatrician and I confess I hadn’t heard about these changes. And they're changes that matter. The new approach means that the many patients getting PT at home who are no longer improving in their function but who are very likely to deteriorate if they stop getting PT are eligible for “maintenance” therapy. It means that patients in a post-acute facility after hospitalization who are using PT to get back on their feet don’t necessarily lose their SNF coverage as soon as their gains in physical function level off—provided the therapist has compelling reason to believe that further therapy is required to consolidate those gains.

The ruling to date appears to be narrowly confined to therapy services. But surely the same argument holds for nursing care: older people at home who get visiting nurse services, for example, are not currently eligible for ongoing nursing care, even though they may relapse when acute services are discontinued.

On balance, what is effectively an expansion of coverage is good for patients. Discontinuing beneficial services is often short-sighted, resulting in more acute illnesses, more hospitalizations, and more costs. But there is a problem. How do you know whether ongoing therapy (or nursing care) is necessary to maintain the gains that have already been made? And if you don’t know (without stopping the therapy and seeing what happens), how can you avoid over-use? It’s not so simple. And it all hinges on the "reasonable and necessary" standard that governs all Medicare coverage decisions.

The "reasonable and necessary" language was written into the original 1965 Medicare statute. It has bedeviled Medicare for years. This language has been interpreted to mean that Medicare may not make decisions about what to pay for based on either cost or cost-effectiveness--though many thoughtful people believe that paying a huge amount of money for a procedure or drug that doesn't do much good is completely unreasonable. This language has been interpreted to mean that the results of comparative effectiveness studies, evaluations that have the potential to disclose, for example, that approach A is identical to approach B in effectiveness but is twice as expensive, may not be used to limit Medicare coverage.

The phrase "reasonable and necessary" has been the source of no end of trouble. It is meant to be clear and precise, but it's neither. Past attempts to modify the law to define more clearly what Medicare is required to cover have met with stiff resistance from device manufacturers and other corporate interests in maintaining the very permissive status quo. Increasing their access to physical therapy is likely to be a net benefit to patients, but over the long run, we need to find a better way to determine just what Medicare should pay for. That will require legislative action, and it will require a consensus among the relevant stakeholders. If we don't undertake such a process, we risk jeopardizing the viability of the Medicare program itself.