Daniel M. Keller, PhD

July 05, 2016

BERLIN — Medicare beneficiaries with Parkinson's disease (PD) greatly underuse allied health professional services, a cross-sectional study based on Centers for Medicare & Medicaid Services (CMS) records from 2007-2009 shows.

These professional services include physical, occupational, and speech therapy, studies of which have shown their benefits in PD, including improved motor function, independence, and fall prevention, especially with physical therapy.

The findings were presented here at the 20th International Congress of Parkinson's Disease and Movement Disorders.

The study population consisted of 742,846 Medicare beneficiaries with PD age 65 years and older. Files identified diagnosis, treatment, and procedure claims in inpatient and outpatient settings and provider specialties, as well as patient demographics and comorbid conditions. Most of the beneficiaries were white (89.2%) or black (5.8%), half were male, and two thirds were 75 years or older.

"Only 11.1% of persons with Parkinson's disease had claims for physical therapy/occupational therapy, and 11.5% for speech therapy," Michelle Fullard, MD, and colleagues said. "Race was associated with allied healthcare utilization with Asian Americans being the highest users, while African Americans had the lowest utilization."

Table. Adjusted Odds of Use of Allied Healthcare by Patients With Parkinson's Disease

Characteristic Physical Therapy Evaluation Occupational Therapy Evaluation Occupational/Physical Therapy Treatment Speech Therapy
White Reference Reference Reference Reference
Black 0.61a 0.78a 0.67a 0.67a
Asian 1.35a 0.70b 1.52a 1.45a
Hispanic 0.84a 1.50a
Native American 0.67a 0.66a 0.62a
Other/unknown 1.16b 1.20a 1.16a
Male Reference Reference Reference Reference
Female 1.07a 1.16a 1.11a 1.03b
65-69 y Reference Reference Reference Reference
70-74 y 0.94a 0.95a
75-79 y 0.92a 0.88a 0.89a
80-84 y 0.86a 0.79a 0.82a
85 y or older 0.76a 0.72a 0.72a

a P < .001. b P < .05.


Use of allied health services correlated with the number of yearly visits to a neurologist (P < .001). Compared with no neurology visit, any neurology visit was associated with a 50% higher likelihood of a physical therapy evaluation and higher likelihoods of occupational therapy evaluation (48%), occupational/physical therapy treatment (31%), and speech therapy (52%). If patients visited a neurologist more than three times in a year, the odds of receiving these services were 73%, 78%, 47%, and 80% greater, respectively.

The authors noted that the American Academy of Neurology (AAN)'s quality care guidelines state that rehabilitative options (eg, physical, occupational, and speech therapy) should be discussed with PD patients annually regardless of their stage of the disease.

Furthermore, the AAN's clinical guidelines support the use of physical therapy as a primary treatment option for mild, nondisabling parkinsonism. The study authors therefore recommend further research to identify barriers to following the guidelines.

One of those barriers is a lack of availability of allied healthcare providers, which the researchers found particularly troublesome in some upper Midwestern and Southern states.

Possible clues to barriers may be found in looking at the healthcare systems in other countries. The investigators noted that studies of allied healthcare utilization have shown referral rates for physical therapy of 63% in the Netherlands and 43% in the United Kingdom.

Another barrier in the United States may be administrative burden. Peter Schmidt, PhD, senior vice president and chief mission officer of the National Parkinson Foundation in Miami, Florida, told Medscape Medical News it is difficult to get access to allied healthcare in chronic diseases because of a therapy cap.

"People are limited to about a month's worth of occupational therapy, and for some reason, physical therapy [PT] and speech therapy have a combined cap of about a month of use," he said. "And so in order to get people beyond a month a year of PT, OT [occupational therapy], or speech, you have to ask for an exception."

That means paperwork for the physician, and there may be a bias in the patients for whom they are going to fill out the information. The present study showed disparities based on race and age.

Dr Schmidt pointed to a class action suit challenging the "improvement standard" requirement by CMS "where they said that patients had to improve in order to continue allied health therapy." The plaintiffs argued in the case that if a patient can benefit by having a slower degradation instead of an actual improvement in their status, that should be covered, too.

He said that there is no evidence that 1 month of therapy each year is sufficient for a patient with even moderate PD to learn to participate in their own care.

Dr Schmidt's own studies and those of other investigators have shown that physical and occupational therapies can help patients to exercise, which "is one of the most effective ways to even reverse the course of Parkinson's," he said. And the earlier that these services and speech therapy are provided, the better the course of the disease later because learned activities may be stored, but it may be impossible for patients to incorporate new activities later.

The Parkinson's side prevailed in the class action suit. On January 24, 2013, the US District Court for the District of Vermont approved a settlement agreement in that case, Jimmo v. Sebelius. The CMS website now reflects that settlement:

  • No "Improvement Standard" is to be applied in determining Medicare coverage for maintenance claims that require skilled care.

  • Skilled nursing or therapy services are covered where such services are necessary to maintain the patient's current condition or prevent or slow further deterioration safely and effectively.

There was no commercial funding for the study. Dr Fullard and Dr Schmidt have disclosed no relevant financial relationships.

20th International Congress of Parkinson's Disease and Movement Disorders. Abstract 444. Presented June 20, 2016.

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