Medicare SGR Bill Leaves Beneficiary Access Issue Behind

Permanent Repeal of Therapy Cap Excluded in New Legislation Addressing Flawed Provider Reimbursement Under Medicare: More than One Million Medicare Beneficiaries at Risk

(Rockville, MD - March 24, 2015)  

With more than one million Medicare beneficiaries at risk for being denied necessary outpatient therapy services, the American Speech-Language-Hearing Association (ASHA), the American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA) are asking Congress to include a permanent repeal of the therapy cap in new legislation introduced last week to fix the flawed sustainable growth rate (SGR). SGR is the calculation used for reimbursement of providers for outpatient Medicare services.

The Medicare therapy cap and SGR were created when Congress passed the Balanced Budget Act in 1997. The current proposal to repeal the SGR only includes a two-year patch for the therapy cap—a risky approach for Medicare beneficiaries. Without being attached to a larger Medicare reform bill, there is no guarantee Congress will take up the therapy cap issue in two years.

"We need a full repeal of the existing caps on physical therapy, occupational therapy, and speech-language pathology services. These annual financial caps limit services often needed after a stroke, traumatic brain injury, or spinal cord injury, or to effectively manage conditions such as Parkinson's disease, multiple sclerosis, and arthritis. Arbitrary caps on these vital Medicare outpatient therapy services are simply unacceptable," said Senator Ben Cardin (D-MD), a member of the Finance Health Care Subcommittee. "Permanent repeal of these therapy caps should be addressed as part of any legislative proposal to repeal and replace SGR."

"I am concerned that the current, arbitrary caps could prevent Medicare beneficiaries recovering from diseases or conditions that require extensive therapy from receiving the services they need," said Senator Susan M. Collins (R-ME), chairman of the Senate Aging Committee. "It is vital that we ensure patients aren't denied access to care because of arbitrary caps under Medicare as part of the SGR package."

Permanent repeal of the Medicare therapy cap in SGR legislation has already been negotiated and supported by both parties. Approved in the Senate's version of permanent SGR legislation in the last Congress, the alternative policy would create a more targeted approach to treatment outliers—and would focus on therapy outcomes in reimbursement decisions. This is consistent with the revised approach to SGR, which is tied to quality outcomes as opposed to the traditional fee-for-service model.

"It is vital that Congress advances a permanent solution to the therapy cap issue so that Medicare beneficiaries have access to necessary treatment they require and deserve," said ASHA 2015 President Judith L. Page, PhD, CCC-SLP. "We have delayed decisive action for far too long. By addressing the therapy cap in current legislation, we can eliminate uncertainty and act in the best interests of patients and providers."

"If Congress fails to include a permanent solution for the therapy cap in this bill, it will have purposely missed the only significant opportunity in almost 20 years to fix this critical patient issue," said APTA President Paul Rockar, Jr, PT, DPT, MS. "A bipartisan solution has been negotiated. These policies were created together. They should be fixed together."

"Providing certainty in payment through SGR reform without also permanently addressing the therapy cap issue undermines access to care for Medicare beneficiaries seeking much-needed therapies to maintain their quality of life," said Virginia Stoffel, PhD, OT, BCMH, FAOTA, AOTA president. "Any effort to disassociate these two policies will, undoubtedly, compromise Congress' ability to tackle the policy comprehensively in the future."

About the American Speech-Language-Hearing Association
ASHA is the national professional, scientific, and credentialing association for 182,000 audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. Audiologists specialize in preventing and assessing hearing and balance disorders as well as providing audiologic treatment, including hearing aids. Speech-language pathologists identify, assess, and treat speech and language problems, including swallowing disorders.

About the American Physical Therapy Association
The American Physical Therapy Association represents more than 90,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Learn more about the types of conditions physical therapists can treat, and find a physical therapist in your area, by visiting Follow Move Forward PT on Twitter and Facebook.

Founded in 1917, the American Occupational Therapy Association (AOTA) represents the professional interests and concerns of more than 185,000 occupational therapists, assistants, and students nationwide. The Association educates the public and advances the profession of occupational therapy by providing resources, setting professional and educational standards, and serving as an advocate to improve health care. Based in Bethesda, Md., AOTA's major programs and activities are directed toward promoting the professional development of its members and assuring consumer access to quality services so patients can maximize their individual potential. For more information, go to


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