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Lifestyle Modification, Physical Therapy, and Medicare

Posted on: Wednesday, 15 June 2005, 03:00 CDT

APTA testimony highlights the role of physical therapists in promoting healthier lifestyles as the Centers for Medicare and Medicaid Services looks to develop a national coverage policy.

Every physical therapist (PT) or physical therapist assistant (PTA) has confronted Medicare rules and regulations that make him.; or her wonder how on earth the program decided which conditions and treatments to cover, and under what circumstances. Most PTs and PTAs are familiar in a general way with the role Congress plays in setting Medicare policy, and many are aware of the administrative process for issuing . regulations. Some may even have heard of the committee that advises the Centers for Medicare and Medicaid Services (CMS) on coverage issues. It's probably a safe assumption, however, that relatively few PTs and PTAs are aware of the opportunities afforded the profession to raise issues and offer guidance in determining coverage policies. The Medicare Coverage Advisory Committee (MCAC) meets periodically throughout the year to discuss coverage issues determined by CMS.

One such opportunity occurred earlier this year, when Steven Tepper, PT, PhD, represented APTA at a MCAC meeting. The January 25 session featured experts discussing data on, and the quality of clinical evidence pertaining to, the potential effects of lifestyle modification-including exercise, diet, and stress reduction-on the reversal or resolution of coronary heart disease and diabetes. Among the presenters was Dean Ornish, MD, who is well-known in the field of behavioral modification and spoke about the structure and outcomes of his program. As a result of the meeting, CMS is in the early stages of moving toward developing a national coverage decision on lifestyle modification programs. Although the requirements, guidelines, and timing of coverage have yet to be established, Tapper's testimony and APTA's written comments ensure that the role of PTs will be on the minds of committee members as those decisions are made.

PTs and Lifestyle Modification

PTs, APTA emphasized, play a primary role in effective lifestyle modification by teaching proper exercise techniques to patients coping with coronary heart disease or diabetes and by counseling them on managing their conditions and symptoms. Numerous studies show a causal connection between increased physical fitness through therapeutic exercise and reduced risk of developing diabetes, coronary heart disease, hypertension, stroke, breast cancer, and many other diseases. These studies demonstrate that the converse also is true: low fitness levels and poor diets have been shown to lead to greater risks of developing these conditions. Prevention and treatment of such diseases through supervised physical activity, diet, and similar measures also collectively are a cost-effective way to help individuals restore functional capacity, minimize impairments, and maintain health.

The clinical evidence demonstrates that lifestyle modification is an effective and cost-efficient way to reduce the symptoms and risks factors of the aforementioned diseases, and suggests that encouraging life-style modification can be a successful way for Medicare to reduce health care costs to older Americans who could benefit from therapeutic exercise, improved diet, stress reduction, and other lifestyle changes.

Tepper and APTA emphasized to the committee that PTs generally provide services to clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Through individualized exercise techniques, PTs promote lifestyle modification using tailored exercise programs to decrease the effects of diseases such as diabetes and coronary heart disease. Medicare recipients who do not alteady have chronic illnesses, but who may wish to reduce their risk of diabetes, coronary heart disease, and other diseases also may benefit from exercise-based lifestyle modification.

APTAs written presentation pointed out that PTs evaluate clients' needs by gathering data on medical history and other relevant factors, such as health habitssd, and then identifying risk factors and behaviors that may impede optimal functioning. In the cases of clients who have diabetes and coronary heart disease, or have risk factors for such diseases, PTs will develop a plan of care that is tailored to these specific chronic conditions. This plan is established in collaboration with the patient, caregivers, and other health care practitioners, and is based on data from the patients history, systems review, specific tests and measures (including body mass analysis and endurance testing), diagnosis, and comorbidities.

In designing the plan of care, APTA informed committee members, the PT analyzes and integrates the clinical implications of the severity, complexity, and acuity of the pathology/pathophysiology (disease, disorder, or condition), impairment, functional limitation, and disabilities in order to establish the prognosis and predictions about the likelihood of achieving anticipated goals, expected outcomes, and optimal function in the patients daily life.

APTA pointed out that a plan of care for addressing lifestyle modifications to affect a patient's function-as well as to address the symptoms of heart dis ease and diabetes-could include individualized therapeutic exercise to increase physical activity at a level appropriate to the patient's needs and clinical presentation. Such a plan of care includes specific therapeutic activities, often carried out in a home setting, and a discharge plan including follow-up and referral to appropriate health care practitioners. Appropriate follow up ensures patient safety and adaptation as physical status, caregivers, tasks, and environment change.

In its comments, APTA told the panel that PTs work closely with the Medicare population in private practice, inpatient and outpatient rehabilitation facilities, hospitals, skilled nursing facilities, and other settings, and that PTs have extensive education and clinical experience in the aging and disease processes and their impact on patients. PTs examine, evaluate, diagnoset, and provide a prognosis for older Americans with heart disease and diabetes-essential knowledge in designing a plan of care that meets the patient's individual needs and fit his or her clinical presentation. PTs are experts at prescribing exercises at the proper level of intensity, and thus can develop a physical activity plan that meets the health needs of the Medicare patient while helping to avoid joint stress. In many ways, APTA informed the committee, PTs are needed for lifestyle modification within the Medicare population. Factors such as age, other illnesses, and years of detrimental habits make oversight and individualized attention from PTs a necessary part of this treatment.

Quality of Clinical Evidence

The APTA statement advised committee members that, while numerous published studies have demonstrated the positive effects of physical exercise and improved diet on diabetes and coronary heart disease, many of the studies have focused on the general population, not on Medicare-age recipients. APTA pointed out that further studies may be needed, therefore, to assess the benefits of lifestyle modification on Medicare patients, because age and other comorbidities may be significant factors. Also, while most studies show that the positive effects of lifestyle modification can be maintained over extended periods of time, one factor to consider is whether individuals will continue their lifestyle modification once they no longer are supervised by a qualified health care provider for the Medicare population.

The existing evidence on lifestyle modification is persuasive. According to the Centers for Disease Control and Prevention and the American College of Sports Medicine, if adults walked briskly at 3- 4 mph for 30 minutes or more on most, if not all, days of the week, 285,886 deaths from cardiovascular disease would be prevented each year.1 Research from the American Heart Association states that regular physical activity using large muscle groups-such as walking, running, or swimming-produces cardiovascular adaptations that increase exercise capacity, endurance, and skeletal muscle strength. Habitual physical activity also prevents the development of coronary artery dis ease (CAD) and reduces symptoms in patients with established cardiovascular disease. There also is evidence that lifestyle modification through exercise reduces the risk of other chronic diseases, including type 2 diabetes, osteoporosis, stroke, obesity, depression, and cancer of the breast and colon.2

Lifestyle Modification And Coronary Heart Disease

For patients with or at risk of developing coronary heart disease, Tepper and APTA pointed out, studies show that related risk factors such as hypertension, low HDL (high-density lipoprotein or "good cholesterol"), high LDL (low-density lipoprotein or "bad cholesterol"), and elevated FFA (free fatty acids) can be reduced with physical exercise. Improvements in these risk areas have been linked to decreases in plasma insulin levels, and it is likely that many of the beneficial effects of physical activity on cardiovascular risk are related to improvements in insulin sensitivity.

Landmark epidemiol\ogical research highlighted by the Framingham Heart Study has led to widespread public and professional acceptance of the role of risk factors in the development and progression of cardiovascular diseased Guided by epidemiological evidence, clinical trials have been successfully conducted to document prevention of the initial occurrence of atherosclerotic cardiovascular disease (primary prevention), and subsequent development of disability, morbidity, and mortality in patients with manifest atherosclerosis (secondary prevention).

Lifestyle Modification And Diabetes

Type 2 diabetes affects approximately 18 million adults in the United States. In its testimony, APTA stated that compelling evidence indicates lifestyle change prevents or delays the occurrence of type 2 diabetes in high-risk groups. But the Association pointed out that people with diabetes often do not receive the care, education, and support they need to successfully manage the disease4-and noted that PTs can educate people with type 2 diabetes about the physiology of exercise, as well as its potential benefits and complications.

Therapeutic exercise, along with diet and medication, is a crucial component in managing type 2 diabetes and preventing serious complications. Exercise is necessary to achieve cardiovascular fitness, appropriate body composition, and muscular strength and endurance. For diabetes patients, the benefits of exercise include increased insulin sensitivity and decreased serum glucose levels.'' APTA emphasized that it is essential for diis population to be supervised by qualified health care providers, such as licensed PTs, to ensure patient protection from complications such as skin integrity issues and the impact of exercise on blood glucose. In diabetic patients at risk of heart disease, exercise has been shown to lead to reduction in body weight, lower blood pressure, reduced LDL, and increased HDL. 5

Numerous other studies have shown similar reductions in type 2 diabetes and coronary heart disease symptoms and risk factors among people participating in lifestyle modification programs. Moreover, while increased intensity may correspond to greater reductions in symptoms and risk factors, even low-impact physical activity such as brisk walking is sufficient for a noticeable impact on the health of diabetes and heart disease patients. This fact is especially relevant to those within the Medicare population, who are more likely to need individualized therapeutic exercise programs to reduce risk factors without becoming susceptible to other physical impediments.

A Step Toward Improving Medicare Coverage

In the wake of the January hearing, CMS officials indicated interest in moving ahead with developing a coverage decision for lifestyle modification. It won't be an easy policy to draft, given the programs imperative to pay only for services that will have a proven benefit to patients. Physical therapy's interests have been registered at the outset, however, and APTA will continue to work with CSM and keep you informed as the process moves forward.

About MCAC

The Medicare Coverage Advisory Committee (MCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law. It performs this task through review and discussion of specific clinical and scientific issues in an open and public forum. It consists of up to 100 appointed members, each of whom serves a 2-year term. Each MCAC meeting is attended by 12 to 15 members whose selection is based on clinical relevancy. The committee generally meets six to eight times per year and deals with one or more specific clinical topics during each session. For more information, go to www.cms.hhs.gov/mcac/default.asp.

References

1. Pare RR, Pratt M, Blair SN, et ai. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402-407.

2. Thompson P, Buchner D. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation. 2003; 107:3109.

3. Dawber TR, Moore FE, Mann GV. Coronary heart disease in the Framingham Study. Am J Public Health. 1957:47:4-24.

4. Funnell MM, Anderson RM. Working toward the next generation of diabetes self-management education. Am J PrevMed. 2002;22(suppl 4):3- 5.

5. Evans N, Forsyth E. End-stage renal disease in people with type 2 diabetes: systemic manifestations and exercise implications. Phys Ther. 2004;84:454-463.

by Jonathon Morse, JD

Jonathan Morse, JD, is assistent director of the Regulatory Affairs Deportment at APIA. He con be reached atjonathanmorse@apta.org.

Copyright American Physical Therapy Association Jun 2005

Source: PT; Magazine of Physical Therapy

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