California Physical Therapy Association - c.ymcdn.comc.ymcdn.com/sites/€¦ · California Physical Therapy Association (CPTA) ... CPTA told that the implementation was a done deal

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California Physical Therapy Association (CPTA) © 2016

California Physical Therapy Association1990 Del Paso Road

Sacramento, CA 95834

(916) 929-2782

www.ccapta.org www.movecalifornia.org


Grassroots Advocacy Forum: Harvesting the

Garden to Improve the Way

We Move

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Advocating Against the Third-Party Administrator

(TPA) Take Over


Rick Katz, PT, DPT

Chairperson, CPTA Payment Policy Committee


Objectives

The Issues

Historical Overview

CPTA’s Strategy and Consumer Advocacy Campaign

Next Steps as we “Move Forward”

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The Issues

Third Party Administrators

Utilization Management Companies

Narrow Networks and “Middlemen” impact on access

and payment for PT in California


Third Party Administrators (TPAs)

What are they?

Serve as intermediaries between the payer and provider

Creates and/or manages provider network (contract negotiations) on behalf of the payer

Manages utilization of treatment via pre-authorization and re-authorization

Create a ‘narrow’ network of providers to direct care

Provides prospective/retrospective treatment medical review (peer-to-peer and non-peer review)


One Reason Why They Exist- Medical Loss Ratio

The Affordable Care Act established the ability for payers to

appropriate expenses to utilization management to patient care

services vs the 15-20% they are allowed to consider

administrative costs. In essence this creates the incentive for

payers to hire these TPAs to and categorize services as “patient

related”.

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Presence in California

Optum/UHC

American Specialty Health/Cigna

Align (Workers’ Compensation)

MedRisk (Workers’ Compensation)

OrthoNet/Anthem Blue Cross (Limited Regional presence)


Optum

Participated in their Professional Advisory Council

(Included Peter Rigby, Tom DiAngelis, Jeanine Gunn,

Anthony DeFilippo, Dennis Langton, others)

Moved to obtain studies on direct access to PT for

MSK conditions

Open discussion regarding modification of their global

policy on PT


American Specialty Health/Cigna

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The Process at work . . .ASH/Cigna

ASH presented PT providers with a 53 page contract

APTA, CPTA and other components conducted an extensive

review and communicated directly with Cigna and ASH

CPTA hosted a meeting with representatives from both ASH

and Cigna in 2014


CPTA Responds!

Communication via CPTA Payment News e-blasts

Payment forum at annual conference

Individual consulting service

Lobbying for postponement


ASH could not provide an adequate Network in CA!

Revised the Addendums to the contract multiple times

Eliminated pricing for modalities, modified classification of

outliers

Changed pricing based upon individual provider negotiations

Implementation delayed 6 months

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Align Networks


Align

Aggressive discounts off the recently revised California

workers’ compensation fee schedule

Directed care based ONLY on pricing


Anthem announces Orthonet

September 1, 2015 Anthem sends letters to members

indicating that they will use Orthonet to manage their PT/OT

benefits

Claimed PT/OT is a “confusing” benefit

Implementation set for November 1, 2015

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CPTA Responds

CPTA writes letters and makes personal contact with the CA

Department of Managed Healthcare and CDI highlighting the

potential impact on access to care and interference in the

Patient PT Physician

Relationship


CPTA’s Strategy and Consumer Advocacy

Campaign

CPTA launched a major “patient-focused” grassroots campaign urging: Outpatient Providers:

1. Post a notice to all Anthem patients, explaining the potential devastation of OrthoNet managing utilization of PT services

2. Have every Anthem patient write a letter to the Department of Managed Health Care urging them to block the proposed contract

Patients:

1. File a complaint with Anthem

2. Called for communication with employer benefit plan administrators

3. Called for contacting Anthem Grievance Office directly


Anthem Meeting

CPTA meets with Anthem V.P. of Provider Contracting in

New Hampshire and OrthoNet implementation team on

October 21, 2015

Multi-faceted agenda

CPTA told that the implementation was a done deal

Intent of using OrthoNet was to bring consistency across their

14 markets

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Anthem’s Reaction

Delay of rollout for indefinite period

Surprised at CPTA’s aggressive PT/consumer

opposition as they had not experienced this in other

markets

Agreed to continue dialogue


CPTA Stands Firm Against Anthem’s Unwarranted UM

Policy Change


CPTA’s Multi-Pronged Approach

Continued communication with DMHC regarding consumer concern with the proposed UM modification

DMHC contacts CPTA regarding overwhelming volume of opposition calls/letters from consumers and PTs

DMHC confirms Anthem’s application for modification is delayed indefinitely

CPTA Legal Counsel submits Public Records Act (PRA) Request to DMHC on Anthem’s current UM practices

Anthem’s UM data (SLP/OT services) from PRA confirms their inability to oversee UM for current SLP/OT benefits with autistic patients

Anthem referred to DMHC’s Enforcement Dept. for discipline and penalty fines

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DMHC finds Anthem UM to be Inadequate

Specifically, 27% of SLP/OT UM denials did not

contain clear and concise denial language and 17%

did not include clinical reasons for the denial, as

required by law.

The denials did not provide enrollees with adequate

information to understand and appeal the denials

of the health care services they sought, including

mentally ill enrollees.


CPTA provided numerous Online Resources

CPTA’s website was updated daily to outline where to call for

questions while the UM process was on hold

CPTA developed numerous sample letters for consumers and

PTs to use to advocate against the proposed UM change

CPTA provided high-level state contacts for members and

consumers to contact when receiving inaccurate information

from OrthoNet during the onboarding period


Anthem-Cigna Merger Announced

Anthem and Cigna proposed Merger

CPTA uses Anthem’s UM data (SLP/OT services) from

PRA to demonstrate their inability to oversee UM for

current SLP/OT benefits with autistic patients

CPTA testified in strong opposition at EVERY public

hearing on the proposed Anthem/Cigna merger

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CPTA Speaks out against Anthem at DMHC and CDI

Hearing

DMHC and CDI held numerous public hearings to elicit testimony and comments regarding the possible implications of the proposed merger between Anthem, Inc. and Cigna Corporation.

CPTA leadership testified in strong opposition of Anthem and Cigna’s subpar utilization management process, poor provider payment methodologies and unjustified delays to care. CPTA highlighted these shortcomings and demanded that the merger not be approved to ensure California consumers are protected.

We were asked by Commissioner Jones and staff to provide our detailed comments in writing and a follow-up meeting was requested with both groups.


CPTA Gained Major Recognition at CDI Hearing

CPTA was the ONLY non-physician medical provider to

testify at CDI public hearing.

The testimony gained prominence and significance.

This testimony significantly raised the visibility and

access to state officials.

Every APTA component that is experiencing challenges

may want to consider similar strategies and participate in

all pertinent public meetings.


DMHC and CDI wants CPTA Input

DMHC officials request a meeting with CPTA to

discuss the potential impact of the merger

CDI follows with a similar meeting request

CPTA testimony quoted in Insurance Commissioner’s

recommendation letter to US DOJ to block the

proposed merger

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CPTA Meets with CDI and Senate Health

Committee July 2016, CPTA leadership held key meetings with California Department

of Insurance (CDI) Chief Counsel, Deputy Commissioner of Health Policy, as well as the Principal Consultant for the Senate Health Committee to discuss the severe challenges our patients and providers continue to face dealing with network managers such as Align, ASH, Optum and OrthoNet (Out-of-State plans).

Both state organizations were greatly concerned about the current state of health care and agreed to collaborate with us to determine how best to regulate the abuses our profession faces.

The state agencies agreed that barriers to medically necessary care will not be tolerated and share in our concern and want to help.

Emphasized the importance of consumers filing complaints as often as needed to escalate the issues.


US DOJ wants CPTA Input

US DOJ held a conference call with CPTA for testimony on

past and current opinion of Anthem and Cigna’s management

of therapy benefits

CPTA provides data from PRA demonstrating poor UM

practices on Anthem’s part

CPTA provides anecdotal data on Cigna/ASH UM practices


US Justice Department Sue to Block Anthem’s

Acquisition of Cigna The U.S. sued to block Anthem’s proposed acquisition of

Cigna alleging that the transactions would harm competition

across the country

Both Anthem and Cigna have been criticized for improperly

limiting access to physical therapists through mismanaged

utilization review.

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Next Steps as we “Move Forward”


CPTA Makes Payment #1 Area of Focus

Board of Directors prioritize “Payment Issues” as the

#1 priority for the chapter in 2016-2017

Involve membership in payer reform campaign across

all practice settings

Approach payers directly while pursuing regulatory,

legislative or legal remedies


Legal Review

Pursue Legislative Change to limit the % that the state

workers’ compensation fee schedule may be reduced

Pursue Legislative or Regulatory Change limiting Co-

Pay amounts

Research unfair competition and anti-trust laws and

Payer/TPA exemption

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CPTA Held Payment Summit

CPTA held a payment summit which gathered over 20 PTPPs

and billing experts to discuss challenges in payment

Data collection project is launched to collect information on

UM delays


Data Collection Project

Analyze UM data and summarize it for the purposes of

presenting evidence to state regulators to further show

substantial delays to authorize medically necessary care

Present final data project in 2017

Share with APTA and other components


CPTA Formed a Multi-Disciplinary Coalition

CPTA formed a multi-disciplinary Coalition Group to

collaborate in efforts to reform payer abuses

MDs, Dos, DPMs, Radiologists, DCs, Interpreters, etc

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2017 Legislative Fix Legislative

Submit Legislative Counsel Opinion on California Workers’

Compensation Fee Schedule Floor, Anti-Trust Laws and unfair

competition laws in state

Request for a legislative/regulatory change to close the loopholes

in laws/regulations that govern state Workers’ compensation,

private, and commercial health service plans to better serve the

consumers of PT services

Multi-disciplinary Coalition to collaborate on these efforts


How does this impact you now?

Limit on patient visits

Decreased practice profits

Changes the approach to treatment planning

Impact on potential earnings (total compensation package)

WE Need YOU to become advocates for YOUR patients

WE Need YOU to become advocates for YOUR profession

WE Need OUR patients to become advocates for themselves


Questions

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2016 Legislative

Year-End Review

Chris Reed, PT, MPT, OCS, ATC

Government Affairs Chair, CPTA


AB 2507: Tele-health: Definition Expansion

Allows for digital consent

Tele-health definition includes telephone and video

Requires coverage at same extent as if provided in person

Requires reimbursement to provider at a rate at least as

favorable as equivalent services provided in person

Prohibits exclusive contracts between insurers and

independent tele-health providers

Held in Assembly Appropriations due to concerns over cost,

scope of services covered and reliance on provider

determining appropriateness


Youth Sports Bills

AB 2007: Concussions: Youth Sports Organizations

Applies concussion rules from school based athletics to

Youth Sports Organizations.

AB 2182: Concussion Neurocognitive Testing

Establishes a 4 yr grant for 3 school districts to conduct

neurocognitive testing in 12 specified sports with data

reporting to County Department of Education

AB 1639: Sudden Cardiac Arrest Prevention Act

Specifies rules around removal and return to partcipation

for student athletes exhibiting symptoms of cardiac distress

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2017 and beyond

CPTA Legislative Focus

Title 22 Reform

TPA reform

NC-SARA

EMG Legislation

Animal rehab

Dry Needling

Interstate Licensure Compact


Insurance

AB 533: Health Care Coverage: Out-of-Network Coverage

Places protections for patients receiving services provided

by non-contracting providers

Need to dig through this more as there were lots of

amendments in the Senate last week at the end of session

Failed on reconciliation in Assembly


Questions

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Advocacy at Your Comfort Level

James M. Syms PT, DSc

Government Affairs Committee Member

&

CAL-PT-PAC Trustee


What is your comfort level?

Not all individuals are comfortable performing the

same activities.

The system is sleazy; “Politics is dirty”

My personality is best in performing _______

advocacy activities.

I’m a PT, not a politician.

Politicians are out of touch with the real world.

Why bother, Special Interests always get their way.

Someone else will always do it.


Winner MUST be present

Democracy is NOT

“government by the people”,

rather it is

“government by the people who participate”

So where can you fit in?

Where/How can you participate, and

yet still be comfortable?

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Advocacy – The Front Door

Participating in meetings with legislators/regulators

– or their staff.

Requires an intermediate to advanced level of familiarity

with the issue that many physical therapists feel they do not

have.

The Association needs to identify the individual(s) who can

serve this role.


Advocacy – The Front Door

Participating in meetings with

legislators/regulators – or their staff.

The TRUTH of the matter is that we all are

experts in the delivery of heath care (PT) to our

patients. Many of us do recognize this.

Our role as individuals is to make the policy

maker aware of how more effective health care

(including PT) can be delivered.


Advocacy – The Other Doors

Participate in “Call to Action”

An identified time to reach out to policy makers

(legislators and/or regulators) for a concentrated

activity to call attention to our issue.

A State (CPTA) and National APTA) Association’s

coordinated event asking for members to mobilize

and have a concentrated push for a particular

issue.

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Make personal phone calls to the office of the

legislator.

It is deal if you are a constituent of that legislator.

Numbers count here – your call and anyone else (possibly

patients?) who you know and will voice support for the issue.



Attend a community event being held by the

legislator.

Often the legislator reaches out to their constituency and thus

provides an opportunity for them to become familiar with you

(and you with them).

May serve as a mechanism for you to become more familiar

become more comfortable with the advocacy process.



Seek for opportunity to participate on any

of the legislator’s advisory committees.

Find out if the legislator has any community or

“in-house” groups that advise him/her on policy

activities.

Some examples are Health Care, Business, Public

Safety, Elderly, Veterans.

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Host an event for the legislator at

your facility or home. While this seems to be greater involvement (and

thus more intimidating), Chapter and District will orchestrate the event, you may only need to provide a place and time and serve as the delightful host/hostess.

You can be perceived in a very positive light by the legislator and establish a relationship thereafter.



Join the mailing list of the legislator – comment on

their activities.

You will have great familiarity with the legislator’s “agenda”

as a public servant.



Get involved in the legislator’s campaign.

Phone Banking

Walking the district.

Placing of yard signs (including one at your business or

home).

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Social Media, Social Media, Social Media

In real estate, the key is:

“Location, Location, Location”.

Now in advocacy (as it is in most anything) the key is:

Social Media, Social Media, Social Media.

Friend, Like, Retweet, …


Winner MUST be present!

Those who refuse to participate in the

democratic process,

are destined to be

ruled by those who do.


Questions

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ABCs of Profession Advocacy

Paul D. Smith, PT, DPT

Chairperson, CAL-PT-PAC

&

Sean Johnson, PT, DPT, OCS

Trustee, CAL-PT-PAC


ABCs Profession Advocacy

P-Promote Our Profession, Our Practice, Our Philosophy

A-Advocate for Our Profession, Scope of Practice, Patients

C-Contribute to Candidates, Agencies, Legislators


Promoting Our 3 Ps

Human Capital

Education of members, the public, and legislators

Linking our value to our brand

Inviting legislators to Tour our facility, clinic, or Academic

program

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Advocacy Essentials

Developing early relationships

Campaign Sweat Equity

Value of maintaining long standing relationships

Delivering The Ask.

Real Patients, Real Stories, Personal Testimonials


Contribute Annually

Financial Capital

We don’t pay to play.

We do support those who understand our profession, its role

in the healthcare continuum, and who can influence health

care policy and clinical practice


Fundraising

Election year dynamics

Annual Goal

Answering the call

Opportunities

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Elect a PT/PTA to Office

Goal: To elect a Physical Therapist or Physical Therapist Assistant to

office

Donate to funds to assist with supporting a candidate from our

profession

Contribution amount $26.50

Individual candidate Campaign fundraising goal is $100,000

Two paths:

Susan Bonilla

Bill Emmerson


Questions?

Documents

California Physical Therapy Association - c.ymcdn.comc.ymcdn.com/sites/€¦ · California Physical Therapy Association (CPTA) ... CPTA told that the implementation was a done deal