Amendments Adopted to Consider A&M Study/HHSC Report on Therapy for Adjusting Reimbursement Methodology

Amendments 86 and 87 were added and adopted into HB 1 yesterday to allow for the inclusion of the Texas A&M study and subsequent HHSC report to consider reforming the reimbursement methodology for therapy to meet “industry standards”. The author is Rep. Greg Bonnen from the Galveston County District 24.  Rep. Bonnen is a neurosurgeon from Angleton, TX and had simultaneously introduced amendments to increase physician Medicaid reimbursement rates. He is also a graduate and advocate of Texas A&M, the origin of the therapy study. Obviously, his goal is to shift therapy dollars to physicians. Rep. Bonnen is also considered to be an ultra-conservative based on his rankings from conservative associations (voted for a bill to require narcotics testing for all potential recipients of government aid, including children).  Rep. Zerwas followed these amendments with another one (88) that mandates that HHSC consider stakeholder input and access to care issues in making those adjustments. It is now part of the bill to be considered for a vote. The Senate must now consider it in their amendments and adjustments to their budget bill for consolidation.

While Rep. Zerwas laid down a conditional on Rep. Bonnen’s amendments, it is a band-aid since HHSC may simply redefine: (1) who is a stakeholder and what form of input will be appropriate (whom will they listen to – TAHCH, OPIRA, other independent therapist organizations, individual therapists, Medicaid advocates, including family members and patients, and in what form will they accept suggestions and/or contrary evidence, testimonials, and alternative academic or analytics studies), and (2) what is an “access to care” issue, (i.e., what statistics are needed to demonstrate that Medicaid children are not receiving proper access to therapy care as dictated by their primary care physician in conjunction with the case supervising therapist). The last issue should include a creditable estimate on the growth of Medicaid population during the next biannual, the needed amount of therapy (per code), and the corresponding fiscal amount to cover those services.

Two things were accomplished with this action – first, we know who Texas therapy’s adversaries are or at least those less sympathetic to Medicaid therapy, in this go around of the Legislature, and second, the A&M study is not going to be scrutinized unless by force of a possible legal action or reconsideration of the study by HHSC through stakeholder input with proper statistical analysis presented. Again, we know the numbers presented by the HHSC report on acute care therapy services. We know that from the 83rd Legislature, $200M is targeted for therapy for the next biannual. Evaluations are most likely first on the chopping block, but it will be a numbers game because one should consider utilization patterns on each therapy code as paid by Medicaid.

The logical thing to do (and who will be logical at this point) is to consider the weight applied to the utilization rank of each code paid. This weight could be applied to the total of $200M (or whatever will be their target). Consideration of the delivery model fee schedule should also be executed utilizing the real relative value unit (RVU) of work for each model as applied to that code service. Old and used arguments for each delivery model are known to all – ORF/CORFs are scrutinized for being a class of hospital/clinic in a fixed setting with added costs of administration and compliance imposed as such, home health agencies are also scrutinized by DADS for administrative prowess and for the cost of travel and certain other compliance issues, and independents (general rehabs-multi-specialty or individuals) are flexible in doing both, albeit within the confines of an individual therapist’s NPI but with little scrutinization for administration and clinical settings. How would one then apply the appropriate RVUs and weights? No empirical studies exist that compare the effectiveness and efficacy of each delivery model. You will hear anecdotal testimony from many at hearings and in closed door meetings with the HHSC. Additionally, very little peer and editor-reviewed research is done and released to the public for therapy regimens to begin with. Therein lies a problem with putting therapy care on the same ground with medical care or at least as an integral part of the continuum of care for Medicaid children in need. The therapy industry must face these issues directly in practices, schools, and research and hospital institutions.

The game is once again afoot. QDR has not yet received news of being able to receive the A&M study and contract, but the State has until next Monday (4/6/2015) to decide. In the meantime we are finalizing our own complete study of all states Medicaid therapy rates and weighting scheme for each therapy code.

Write to your state representative and senator informing them of the gravity of the situation with therapy care in Texas and to the effects that these amendments would have on the Medicaid population and businesses in Texas, in general. Also inform them of the Zerwas Amendment that mandates that HHSC must have input from stakeholders of the industry (including and especially yourself) through letters to and correspondence with the HHSC and the Legislature and needs to consider the effect any rate reduction on therapy codes would have on access to therapy care in Texas. Offer viable alternatives to the amendments and the proposed cost containment plan for therapy such as consideration of a more scientific study of therapy in the US rather than the deprecated A&M study. This is ground-zero for therapy now.