The RHEO Knee®
For transfemoral amputees, the proper choice of a knee is vital for achieving mobility, control, and confidence. Knees must provide reliable support when standing, allow smooth, controlled motion when walking, and permit unrestricted movement for sitting, bending, and kneeling. Prosthetists consider an individual's age, health, activity level, lifestyle, and goals for ambulation before making a recommendation on the most suitable knee for a patient.
Microprocessor knees offer enhanced mobility and research has found other user benefits, such as increased stability and confidence, reduced cognitive burden, higher quality of life, and expanded activity levels, all impacting the overall health and well being of patients.
The RHEO Knee® is known as "the first artificially intelligent knee system that has the ability to learn and adapt to its user's movements, resulting in a continually improved and optimized performance." Manufacturer Össur collaborated with the Massachusetts Institute of Technology to produce a knee that automatically learns and adapts to the user's movements and adjusts swing and stance resistance for optimal response and stability without the need for programming. It compiles information about the wearer's movements and programs itself. However, a set-up mode does allow a prosthetic practitioner to fine tune parameters.
The computer-equipped RHEO Knee calculates the wearer's posture and position in the environment based on feedback from sensors. The artificial joint then adjusts its level of resistance - mimicking the natural motion of a knee - through a "magnetorheological" fluid, a damping liquid controlled by an electromagnet.
- Auto adaptive real-time stance and swing control.
- Dependable and easy swing initiation on all surfaces.
- Automatic stumble recovery.
- Manual extension lock.
- Weatherproof design allows exposure to fresh-water splashes.
- Smart Extension makes raising from a squatted position easier with less resistance.
- Facilitates stepping over obstacles and stepping backwards.
The RHEO Knee family also includes the RHEO Knee 3 and RHEO Knee XC
RHEO Knee 3 aims to provide natural knee function by continuously adapting to the user and environment. The product is designed to offer users swing initiation that enables a smoother gait, in spite of potential obstacles such as crowds and confined spaces. Its improved toe clearance also targets a decreased risk of falling. The device’s actuator and resistance control is engineered to ensure maximized resistance, and its constant power spring provides natural progression in swing. The RHEO Knee 3 also features five-sensor gait detection, including new gyroscope technology, built to target stability and dynamic response in a variety of situations.
RHEO Knee XC is designed to support patients from early rehabilitation to full recovery with intuitive and stable functionality. It supports increased mobility including cycling, walk-to-run, and stair ascent. It features auto-adaptive, real-time stance and swing control with dependable swing initiation on all surfaces. The knee is designed to allow for automatic stumble recovery and features a manual extension lock. It is weatherproof against exposure to fresh-water splashes.
Microprocessor Knees to Suit a Variety of Needs
Since 1997 with the introduction of the first microprocessor knee, the market has expanded to offer users, physicians and practitioners a variety of choices, including but not limited to the following:
Ottobock’s C-Leg and Compact™ microprocessor-controlled knees are designed to deliver the best in stability and reliability, even walking down stairs step-over-step and walking up and down inclines. The on-board computer built into the knee senses and calculates the needs of the user more than 50 times a second.
Ottobock C-Leg® 4:
The C-Leg 4 improvements include advanced stumble recovery, a control feature that improves the transition to swing phase and makes walking backwards safely possible. Sensors determine where the prosthesis is in space at all times and make precise adjustments at every moment of every step. Plus it’s a weatherproof knee, meaning that it is splash resistant if caught in a rain storm.
Genium Microprocessor Knee
The Genium is the latest in microprocessor-controlled knee technology from ottobock. It virtually duplicates a body’s natural, physiological gait phase by phase, no matter what the walking speed, to improve walking, wearer comfort, and accessibility. Optimized physiological gait (OPG) reduces ground reaction forces, improving damping and promoting knee flexion, which helps minimize future orthopedic problems. The Genium can read movement at 100 times a second using multiple sensors and controllers, and its OPG reduces the mental effort and energy required of users when changing speed, walking up or down stairs or hills, avoiding obstacles, and walking backwards. It also allows wearers to stand and sit more easily and naturally.
With this leg prosthetic system from ottobock, the virtually natural replication of the physiological human gait is possible. The X3 opens up entirely new possibilities: showering, going swimming or at work – since the system is water and corrosion-resistant, it stands up to any ambient conditions. Walking backwards, climbing stairs step-over-step or walking at changing speeds and with different stride lengths – the joint is intuitive to use and flexible in adapting to the circumstances. The running mode was developed especially for sports. This mode provides the settings needed for jogging or running. Overall, the X3 offers five additional configurable modes.
Freedom Innovations’ Plié® 3 Knee
Freedom Innovations’ microprocessor-controlled Plié Knee uses advanced algorithms to control stance and swing, and stumble recovery parameters. These parameters are customized for each user’s unique gait pattern, providing confidence that stance resistance will be there over a broad spectrum of activities. Stronger construction makes the Plié 3 both submersible and more rugged than ever. With the most responsive stumble and fall protection, users can instinctively move at their own pace in any direction … even if it’s taking small short steps or pivoting in confined spaces.
Orion3 is suitable for K3 users who would benefit from stability on different terrains, slopes and steps and for those wishing to walk naturally and efficiently at either single or varying speeds. The safety and stability of Orion3 encourages users to evenly distribute their weight, offloading their sound side and lower back to reduce aches and pains commonly reported by amputees.
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Designs and performance of three new microprocessor-controlled knee joints. Thiele J1, Schöllig C1, Bellmann M2, Kraft M1
Abstract: A crossover design study with a small group of subjects was used to evaluate the performance of three microprocessor-controlled exoprosthetic knee joints (MPKs): C-Leg 4, Plié 3 and RHEO Knee 3. Given that the mechanical designs and control algorithms of the joints determine the user outcome, the influence of these inherent differences on the functional characteristics was investigated in this study. The knee joints were evaluated during level-ground walking at different velocities in a motion analysis laboratory. Additionally, technical analyses using patents, technical documentations and X-ray computed tomography (CT) for each knee joint were performed. The technical analyses showed that only C-Leg 4 and RHEO Knee 3 allow microprocessor-controlled adaptation of the joint resistances for different gait velocities. Furthermore, Plié 3 is not able to provide stance extension damping. The biomechanical results showed that only if a knee joint adapts flexion and extension resistances by the microprocessor all known advantages of MPKs can become apparent. But not all users may benefit from the examined functions: e.g., a good accommodation to fast walking speeds or comfortable stance phase flexion. Hence, a detailed comparison of user demands and performance of the designated knee joint is mandatory to ensure a maximum in user outcome.
Conclusion: The C-Leg 4, Plié 3 and RHEO Knee 3 offer a reliable detection of stance and swing phase and the generation of joint resistances to avoid uncontrolled flexion of the knee joint. As shown in the technical analysis, only C-Leg 4 and RHEO Knee 3 allow for microprocessor-controlled adaptation of resistances to different movements and situational requirements. The Plié 3 has manually adjustable elements that generate the resistances. This directly affects the outcome of the biomechanical analysis which examined level walking at different walking velocities. C-Leg 4 showed the most natural knee function when compared to the contralateral side and this was followed by RHEO Knee 3.
Read more: DOI.org
Outcomes associated with the use of microprocessor-controlled prosthetic knees among individuals with unilateral transfemoral limb loss: a systematic review. Sawers AB1, Hafner BJ.
Abstract: Microprocessor-controlled prosthetic knees (MPKs) have been developed as an alternative to non-microprocessor-controlled knees (NMPKs) to address challenges facing individuals with lower-limb loss. A body of scientific literature comparing MPKs and NMPKs exists but has yet to be critically appraised. Therefore, we conducted a systematic review to examine outcomes associated with the use of these interventions among individuals with transfemoral limb loss. A search of biomedical databases identified 241 publications, of which 27 met the inclusion and exclusion criteria and were reviewed for methodological quality and content. We developed 28 empirical evidence statements (EESs) in 9 outcome categories (metabolic energy expenditure, activity, cognitive demand, gait mechanics, environmental obstacle negotiation, safety, preference and satisfaction, economics, and health and quality of life) based on findings in the literature. The level of evidence supporting these EESs varied due to quantity, quality, and consistency of the results. EESs supported by a moderate level of evidence that noted significant differences between MPKs and NMPKs were derived in five of the nine outcome categories. The results from this review suggest that evidence exists to inform clinical practice and that additional research is needed to confirm existing evidence and better understand outcomes associated with the use of NMPKs and MPKs.
Conclusion: We reviewed the body of scientific, peer-reviewed literature in an effort to identify changes in outcomes associated with the prescription, fit, and use of MPKs when compared with NMPKs among individuals with unilateral TFLL. We identified nine outcome topics (metabolic energy expenditure, activity, cognitive demand, gait mechanics, environmental obstacle negotiation, safety, preference and satisfaction, economics, and health and QOL) and generated EESs related to each topic. Varying levels of evidence exist to indicate that the prescription, fit, and use of swing and stance MPK lead to changes in outcomes for individuals with unilateral TFLL when compared with NMPKs.
Moderate evidence exists to suggest that swing and stance MPKs are associated with increased confidence during ambulation, increased self-reported mobility, reduced self-reported cognitive demand while walking, improved self-reported well-being, and equivalent overall societal costs when compared with NMPKs. Low evidence indicates that these MPKs are also associated with increased walking speed on uneven terrain, improved gait patterns in stair descent, decreased numbers of falls, greater user satisfaction, greater user preference, decreased rate of O2 consumption while walking at SSWS, increased SSWS, and increased knee moment in early stance. Moderate to low evidence suggests that swing and stance MPKs and NMPKs result in similar levels of activity, cognitive burden while walking, self-reported general health, rate of O2 consumption at SSWS, O2 cost over a range of walking speeds, and spatial symmetry. Insufficient evidence exists to assess the effect of swing and stance MPKs on temporal symmetry, peak knee-flexion angle, and prosthetic-side hip power. Low evidence suggests that swing-only MPKs are associated with increased user-reported preference compared with NMPKs. Moderate to low evidence indicates that swing-only MPKs produce similar rates of O2 consumption while walking, cognitive burden while walking, SSWS, and spatial symmetry to NMPKs. No evidence suggests that NMPKs provide improved clinical outcomes when compared with MPKs within this body of literature.
This article represents the most comprehensive and detailed collection of evidence regarding the influence of MPKs on the rehabilitation of individuals with unilateral TFLL. Given the current level of empirical evidence, we can conclude that MPKs are indicated for those individuals who require an increase in safety or an improved ability to descend stairs and/or negotiate uneven terrain. The provision of an MPK is also likely to be met with improved patient preference and satisfaction, an improved perception of mobility, and a reduced perception of the effort required for ambulation. Further, MPKs appear to offer these benefits at equivalent total prosthetic rehabilitation costs compared with traditional alternatives. Based on the available evidence, MPKs do not appear to influence outcomes related to O2 consumption, physiological measures of cognitive demand, or the amount of daily activity performed. These findings may be used to indicate those individuals with unilateral TFLL for whom this prosthetic knee technology is most appropriate.
Assessment of transfemoral amputees using a passive microprocessor-controlled knee versus an active powered microprocessor-controlled knee for level walking. Creylman V1, Knippels I2, Janssen P2, Biesbrouck E2, Lechler K3, Peeraer L2,4.
Abstract: In transfemoral (TF) amputees, the forward propulsion of the prosthetic leg in swing has to be mainly carried out by hip muscles. With hip strength being the strongest predictor to ambulation ability, an active powered knee joint could have a positive influence, lowering hip loading and contributing to ambulation mobility. To assess this, gait of four TF amputees was measured for level walking, first while using a passive microprocessor-controlled prosthetic knee (P-MPK), subsequently while using an active powered microprocessor-controlled prosthetic knee (A-MPK). Furthermore, to assess long-term effects of the use of an A-MPK, a 4-weeks follow-up case study was performed.
Conclusion: The range of motion of the knee was higher on both the prosthetic and the sound leg in the A-MPK compared to the P-MPK. Maximum hip torque (HT) during early stance increased for the prosthetic leg and decreased for the sound leg with the A-MPK compared to the P-MPK. During late stance, the maximum HT decreased for the prosthetic leg. The difference between prosthetic and sound leg for HT disappeared when using the A-MPK. Also, an increase in stance phase duration was observed. The follow-up study showed an increase in confidence with the A-MPK over time.
To read more: BioMedCentral.com
The comparison of transfemoral amputees using mechanical and microprocessor- controlled prosthetic knee under different walking speeds: A randomized cross-over trial. Cao, Wujinga; b; * | Yu, Hongliua; b; c | Zhao, Weilianga; b | Meng, Qiaolinga; b; c | Chen, Wenminga; b
Abstract: The microprocessor-controlled prosthetic knees have been introduced to transfemoral amputees due to advances in biomedical engineering. A body of scientific literature has shown that the microprocessor-controlled prosthetic knees improve the gait and functional abilities of persons with transfemoral amputation. OBJECTIVE: The aim of this study was to propose a new microprocessor-controlled prosthetic knee (MPK) and compare it with non-microprocessor-controlled prosthetic knees (NMPKs) under different walking speeds. METHODS: The microprocessor-controlled prosthetic knee (i-KNEE) with hydraulic damper was developed. The comfortable self-selected walking speeds of 12 subjects with i-KNEE and NMPK were obtained. The maximum swing flexion knee angle and gait symmetry were compared in i-KNEE and NMPK condition. RESULTS: The comfortable self-selected walking speeds of some subjects were higher with i-KNEE while some were not. There was no significant difference in comfortable self-selected walking speed between the i-KNEE and the NMPK condition (P= 0.138). The peak prosthetic knee flexion during swing in the i-KNEE condition was between sixty and seventy degree under any walking speed. In the NMPK condition, the maximum swing flexion knee angle changed significantly. And it increased with walking speed. There is no significant difference in knee kinematic symmetry when the subjects wear the i-KNEE or NMPK.
Conclusions: The results of this study indicated that the new microprocessor-controlled prosthetic knee was suitable for transfemoral amputees. The maximum swing flexion knee angle under different walking speeds showed different properties in the NMPK and i-KNEE condition. The i-KNEE (microprocessor-controlled) was more adaptive to speed changes. There was little difference of comfortable self-selected walking speed between i-KNEE and NMPK condition.
To read more: Content.IOSpress.com
A clinical comparison of variable-damping and mechanically passive prosthetic knee devices. Johansson JL1, Sherrill DM, Riley PO, Bonato P, Herr H.
Abstract: Although variable-damping knee prostheses offer some improvements over mechanically passive prostheses to transfemoral amputees, there is insufficient evidence that such prostheses provide advantages at self-selected walking speeds. In this investigation, we address this question by comparing two variable-damping knees, the hydraulic-based Otto Bock C-leg and the magnetorheological-based Ossur Rheo, with the mechanically passive, hydraulic-based Mauch SNS.
Conclusion: The results of this study indicate that variable-damping knee prostheses offer advantages over mechanically passive designs for unilateral transfemoral amputees walking at self-selected ambulatory speeds, and the results further suggest that a magnetorheological-based system may have advantages over hydraulic-based designs.
To read more: NCBI.NLM.NIH.gov
Safety and function of a prototype microprocessor-controlled knee prosthesis for low active transfemoral amputees switching from a mechanic knee prosthesis: a pilot study. Hasenoehrl T1, Schmalz T2, Windhager R3, Domayer S4, Dana S1, Ambrozy C1, Palma S1, Crevenna R1.
Abstract: Aim of this pilot study was to assess safety and functioning of a microprocessor-controlled knee prosthesis (MPK) after a short familiarization time and no structured physical therapy.
Five elderly, low-active transfemoral amputees who were fitted with a standard non-microprocessor controlled knee prosthesis (NMPK) performed a baseline measurement consisting of a 3 D gait analysis, functional tests and questionnaires. The first follow-up consisted of the same test procedure and was performed with the MPK after 4 to 6 weeks of familiarization. After being refitted to their standard NMPK again, the subjects undertook the second follow-up which consisted of solely questionnaires 4 weeks later.
Conclusion: Our results showed that although the Genium with Cenior-Leg ruleset-MPK (GCL-MPK) might help to improve several safety-related outcomes as well as gait biomechanics the functional potential of the GCL-MPK may have been limited without specific training and a sufficient acclimation period. Implications for Rehabilitation Elderly transfemoral amputees are often limited in their activity by safety issues as well as insufficient functioning regarding the non microprocessor-controlled knee prostheses (NMPK), thing that could be eliminated with the use of suitable microprocessor-controlled prostheses (MPK). The safety and functioning of a prototype MPK (GCL-MPK) specifically designed for the needs of older and low-active transfemoral amputees was assessed in this pilot study. The GCL-MPK showed indicators of increased safety and more natural walking patterns in older and low-active transfemoral amputees in comparison to the standard NMPK already after a short acclimatisation time and no structured physical therapy. Regarding functional performance it seems as if providing older and low-active transfemoral amputees with the GCL-MPK alone without prescribing structured prosthesis training might be insufficient to achieve improvements over the standard NMPKs.
To read more: NCBI.NLM.NIH.gov
Economic Value of Advanced Transfemoral Prosthetics. Harry H. Liu, Christine Chen, Mark Hanson, Ritika Chaturvedi, Soeren Mattke, Richard Hillestad
Compared with NMPKs, MPKs are associated with sizeable improvements in physical function and reductions in incidences of falls and osteoarthritis. Our simulation results show that over a ten-year time period, compared with NMPKs, MPKs are associated with an incremental cost of $10,604 per person and an increase of 0.91 quality-adjusted life years per person, resulting in an incremental cost of $11,606 per quality-adjusted life year gained. The results suggest that the economic benefits of MPKs are in line with commonly accepted criteria for good value for money and with those of other medical devices that are currently covered by U.S. payers.
To read more: Rand.org
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The Fathers of the Microprocessor: Federico Faggin, Masatoshi Shima, Marcian “Ted” Hoff, Stan Mazor
Federico Faggin led the development team of the first commercially available microprocessor – the Intel 4004, a 4-bit central processing unit (CPU).
The 4004 (1971) was made possible by the advanced capability of the Silicon Gate Technology (SGT) being enhanced through the novel random logic chip design that Faggin created. It was this new methodology, together with his several design innovations, that allowed him to fit the microprocessor in one small chip.
In 1970, the architecture and logic design of a simple CPU had been done many times before, becoming fairly routine tasks. What had not been done before was to creatively do the circuit design and the layout of such a complex chip as the 4004 to fit into a small enough chip to be commercially viable. That was Federico Faggin's key contribution, made possible by his intimate knowledge of the MOS silicon gate technology he developed at Fairchild Semiconductor two years before. Faggin was also very familiar with computer architecture and with logic design since he had co-developed and built an early experimental electronic computer at Olivetti R&D Labs in Italy before coming to the US.1
Faggin has been recognized with numerous awards for his work including the Marconi Prize; W. Wallace McDowell Award, Kyoto Prize, and Enrico Fermi Prize. In 2010 Faggin received the 2009 National Medal of Technology and Innovation, the highest honor the United States confers for achievements related to technological progress.
Masatoshi Shima worked for Busicom, a business calculator manufacturer in Japan. When Busicom decided to use large-scale integration circuits in their calculator products, they approached Intel for manufacturing help.
Shima, a software and logic engineer responsible for the Busicom calculator design, worked at the Intel offices for six months in 1970, assisting Faggin with logic design, circuit design, chip layout, tester design and test program development.
Because Busicom had commissioned the chip, it had exclusive rights to the design. However, Intel offered to give Busicom a break on the cost if Intel could sell the 4004 to noncalculator applications. Busicom agreed.2
In 1997 Shima won the Kyoto Prize for Advanced Technology.
Marcian “Ted” Hoff, head of Application Research Department, joined Intel in 1968 and is best known as the architect of the 4004. He devised a computing architecture that combined memory, calculating and processing on one circuit rather than scattering them among many custom-designed circuits.
Hoff is the recipient of many awards and was inducted into the National Inventors Hall of Fame in 1996. He received the National Medal of Technology and Innovation in 2009 from President Barack Obama.
Stanley Mazor joined Intel in 1969 after working at Fairchild Semiconductor as a programmer and computer designer. At Intel he worked with Faggin and Hoff on the Busicom calculator’s instruction set and architectural specification and then on the development of the 4004. Mazor also wrote the software for the Intel 4004 chip. He is a recipient of the Ron Brown American Innovator Award and the Kyoto Prize, and the 2009 National Medal of Technology and Innovation.
The four contributors to the 4004 – Faggin, Shima, Hoff, and Mazor – were inducted as Fellows of the Computer History Museum in 2009.
3 Photos by Dicklyon-Own Work, CC By-SA4.0
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APTA PROVIDES CMS WITH EXTENSIVE COMMENTS ON PROPOSED 2019 MEDICARE FEE SCHEDULE RULE
APTA delivered a set of comments on the U.S. Centers for Medicare Medicaid Services' (CMS) proposed 2019 physician fee schedule that were as wide-ranging as the proposal itself, including qualifications on the proposal to extend the Merit-based Incentive Payment System (MIPS) to physical therapists (PT) and clear opposition to a CMS move to lower payment for services provided "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). Also in the association's comments: recommendations that CMS could strengthen its role in the fight against opioid abuse by better supporting nonpharmacological approaches to pain management, including physical therapy, through payment and education improvements.
The extensive comments were developed in response to a rule that, if implemented, would include some of the most far-reaching changes in payment and reporting to date, moving PTs into the Quality Payment Program (QPP) and ending functional limitation reporting (FLR) requirements. But that's just 1 facet of the proposal: the rule touches on everything from the use of telehealth to additional current procedural terminology (CPT) codes. APTA's comments addressed both big-picture issues and some of the nuts-and-bolts of the proposal.
PTs in MIPS: a move that needs to be carefully implemented.
APTA provided extensive comments to CMS on its proposal to include PTs in QPP—and more specifically in MIPS—characterizing the change as an acknowledgement that PTs "act as integral members of the health care delivery team in outpatient settings."
APTA's comments outlined a number of concerns and issues, mostly centered on the association's concern that PTs could face serious barriers to participation in MIPS unless CMS provides "certain amnesties." The association also recommends that CMS adopt more flexible approaches when it comes to PTs opting in to MIPS participation, as well as the measures CMS would accept should facility-based PTs be required to participate in MIPS in the future (the current proposed rule only includes PTs in private practice settings).
APTA also went on record to support a proposed "Physical and Occupational Therapy Specialty Measure Set" within MIPS, and the continued efforts by CMS to eliminate measures that are "topped-out" through high levels of compliance.
CMS has it all wrong when it comes to adjusting payment for services provided "in part" by a PTA.
Some of the association's strongest criticism of the proposed rule is aimed at CMS efforts to establish payment differentials, set to go into effect in 2022, based on the extent of a PTA's or OTA’s role in a visit. That criticism is centered on what APTA believes is the impossibility of accurately defining when a PTA or OTA has sufficiently provided services "in part" to trigger a payment differential, and the dangers of creating a rule stating that any PTA involvement constitutes an excuse for lower payment rates.
While APTA acknowledges that CMS is bound by law to establish a PTA modifier, the association asserts that CMS isn't obligated to go down the definitional rabbit hole associated with pinning down what constitutes care delivered "in whole or in part" by a PTA. In its comments, the association lays out a multipoint case against establishing rules based on terminology that isn't a term of art or statutorily defined, warning that drawing a line on what constitutes "in part" could quickly lead to confusion and loss of access to care, particularly among beneficiaries in rural areas.
APTA recommends that CMS take more time to reexamine the potential problems and wait until next year's rulemaking to address the "in part" issue. Alternatively, should CMS insist on moving ahead in this rule, the association suggests either of 2 more-straightforward approaches: the so-called "midpoint rule" that would pin 100% reimbursement to whether the majority of services are furnished by the PT; or a "blended rate" approach that splits the fee schedule amount for a code in half and then applies the 100% PT rate to one half, and an 85% rate to the other half, thereby avoiding a single trigger that would shift payment to a lower rate, simply because a PTA provided care "in part."
Should CMS continue down the PTA payment differential path, APTA strongly recommends CMS exempt rural areas, health professional shortage areas, and medically underserved areas from the proposed policy, due to concerns of how it could affect patient access. Earlier this summer, CMS indicated to APTA and the American Occupational Therapy Association (AOTA) that it did not have the statutory authority to exempt these areas. APTA is investigating whether that's true, and APTA and AOTA also are advocating for Congress to commission a US Government Accountability Office study to examine how access to physical therapy and occupational therapy will be impacted by the payment differential.
"Given that a [PT] and PTA frequently deliver team-based care, we have serious concerns that requiring the modifier to be applied if any minute of outpatient therapy is delivered by the PTA has serious implications for beneficiary access to care," APTA writes. "Physical therapists and PTAs serve a critical role in the health and vitality of this nation. It is imperative that Medicare beneficiaries continue to have access to high-quality physical therapy services."
More can be done to fight the opioid crisis if CMS would provide stronger support of (and better payment for) nonpharmacological approaches to pain management.
APTA recommends that CMS not only step up its promotion of access to team-based nondrug pain management, but that it back up this support with "subregulatory revisions" that could increase patient access through changed payment models. The association also recommends that CMS reduce or eliminate copays for nonpharmacological pain treatments, and that the agency increase efforts to educate both prescribers and the public on the effectiveness and availability of approaches to pain that don't involve the use of opioids.
Additionally, APTA has a suggestion for providers who continue to prescribe opioids for pain: make a referral to physical therapy a requirement.
"CMS and other stakeholders must ensure that not only is education for providers enhanced, but that a clear, direct path exists for patients in pain to access all treatment options, including physical therapy," APTA writes. "Given that [the US Centers for Disease Control and Prevention] has concluded that there is insufficient evidence that opioid usage alone improve functional outcomes for those in pain, we recommend that clinicians who prescribe an opioid for pain also must be required to refer a patient to physical therapy."
Other provisions in the proposed rule didn't escape APTA's notice.
As is usually the case, the proposed fee schedule covered a lot of regulatory ground. APTA took an equally comprehensive approach in its comments, touching on these additional areas:
- Barriers to PTs participating in alternative payment models (APMs). While PTs technically are allowed to participate in APMs, APTA argues that from a practical standpoint, the profession is at a disadvantage thanks to barriers thrown up by CMS around the use of certified electronic health record technology (CEHRT). CMS requires at least 75% of all eligible clinicians to use CEHRT—the problem is, PTs have been exempt from "meaningful use" criteria promoting interoperability, and there is a lack of physical therapy-specific CEHRT. The result? "[PTs] are essentially barred from participating in advanced APMs," APTA writes. The association is also advocating to Congress to require CMS to develop physical therapy-specific certification criteria for electronic health record vendors.
- Payment for technology-based communications. APTA supports CMS efforts to provide payment for physician communications provided via technology and has asked CMS to clarify whether PTs are included in the list of eligible providers. If not, APTA says, CMS should study that possibility and consider expanding provisions in the future
- Qualified Clinical Data Registry (QCDR) proposals. Because QCDRs such as APTA's Physical Therapy Outcomes Registry could play such an important role in future value-based care models, the association is paying particular attention to CMS proposals for who gets to be included as a QCDR, and the nature of the relationship between a QCDR and CMS. Specifically, APTA supports a CMS plan to require a QCDR entity to have clinical expertise in medicine and measure development, and it backs the measures selection criteria proposed by CMS. However, the association isn't on board with a CMS proposal that beginning in the 2021 payment year, all approved QCDRs must enter into a licensing agreement with CMS that would allow any QCDR to report on any MIPS measure.
- Price transparency. In response to a CMS request for perspectives on price transparency, APTA stated its general support for greater transparency but recommended that CMS study state-level initiatives first. The association also cautioned CMS to be careful about how it defines "cost" from a consumer perspective and to avoid divorcing issues of cost from concepts of quality. Additionally, APTA recommended that any price transparency effort be accompanied by extensive public education efforts.
APTA has additional information and resources on the proposed 2019 physician fee schedule, including fact sheets on the proposal and links to pages with specific information on QPP, MIPS, and APMs. Start with the Medicare Physician Fee Schedule webpage, and sign up for the upcoming webinar, "Everything you need to know about the Quality Payment Program."
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PPTA Annual Conference, October 19-21, 2018, Valley Forge Casino Resort, King of Prussia, PA.
For more information, PPTA.org/MovePA
APTA’s Combined Sections Meeting, January 23-26, 2019, Walter E. Washington Convention Center, Washington, D.C.
For more information, APTA.org/CSM
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