By far, productive aging offers one of the greatest OT practice opportunities of the future. About 78.5 million Americans born between the years 1946 and 1964 entered the geriatric health care market in 1996, and the first set of them will become eligible for the Medicare rolls in 2011.

These people are entering old age generally healthy. They are most at risk for lifestyle-related illnesses such as lung cancer, diabetes and heart problems. They do not consider themselves "old" and spend a lot of money trying to stave off aging. They have created today's wellness market.

Occupational therapy can branch out in many directions with this population. Therapists can target lifestyle-based practice toward those who are not yet retired, incorporating the full spectrum of occupation-based services. Or they can focus on retirees, who are covered by Medicare. Eventually, all the boomers will be moving into this stage, of course.

Medicare pays for home care in two separate ways. Its home health benefit under Part A serves only those who are "homebound," under the care of a physician, and need intermittent skilled nursing, physical therapy or speech therapy. Continuing occupational therapy may be provided upon referral. It is not a qualifying service to open a home health case.

Home care provided under Medicare Part B, for which the patient pays a premium, has no such stipulation. It is a function of outpatient care that serves to aid people in returning to full function in their homes after illness or injury.

Part A services are paid entirely with entitlement funding that comes from Medicare taxes on the income of people who are still working. Keeping these costs in check is a high priority of Congress. Part B services are actual policies for which retirees pay premiums up front.

Definitions in both parts, and the rules that revolve around them, have been subject to change over time as Congress has tried to keep home care costs that were soaring in the 1990s in check. Prospective payment entered the home health care arena in 2000, replacing fee-for-service payment with a formulated payment system based on projected care. Medicare sought functional gains as its outcomes. This year, the PPS New Rule that has gone into effect puts therapy front and center in the process and changes the payment equation.

Rehab therapists will be able to estimate the number of visits they think will be necessary after evaluation, and the agency may choose one of several visit plans, up to 20, with options for more as necessary. This should help put therapists back in control of the length of their treatment if they demand that right.

Since the advent of PPS in home care, some agencies have required their therapists to plan for the maximum number of treatment sessions allowable to increase reimbursement. Instead of standing against this trend, which is in violation of their code of ethics if not their licensure laws, many clinicians altered their clinical reasoning patterns to accommodate the demand. After a while, these therapists forgot the big picture-the occupational picture-of their clients. They began to accept simple tasks as occupational goals.

It is up to OTs and OTAs not to fall victim to this kind of pressure from their employers. In fact, in home health, good management solves most problems.

So how important is it that occupational therapists gain qualifying status in home health? They've been without it now for more than three decades.

No one really seems to be able to gauge that. OT has been successful in home care without it, and some therapists say the right to open cases really just means a lot more paperwork. Those who have spent their careers pushing for qualifying status are frustrated and almost ready to give up.

During the 1980s, the main reason for keeping us off that roster had to do with the Congressional Budget Office's number crunching. The CBO decided that having OT as a qualifying service in home health would drive up the costs of the benefit by adding too many people to the rolls and would probably increase social work and aide visits as well.

The payment structure changed in 2000 from fee-for-service to PPS, but the CBO has never re-calculated the cost of adding OT as a qualifier for home health.

In the past few years, AOTA has had legislation introduced in the House to do this, but couldn't get a co-sponsor in the Senate. In the last round, only 13 Congressmen signed on as co-sponsors of the bill, HR 3022, introduced by Rep. Robert Andrews (D-NJ) in 2005.

Advocates of OT home care legislation are re-thinking whether there might be an easier, quicker road to the goal.

The problem with doing nothing at all is that in legal terms, occupational therapy doesn't exist in home care unless someone else gives it credibility. OT cannot do initial assessments in home care, so PTs usually go in and do that when a referral comes in. OTs depend on PTs and SLPs to recognize the need for OT and relay it to those who complete the in-takes. In a tight market, with PT actively trying to expand its scope of practice into more functional areas, this is dangerous. The trend in medicine will be to keep patients at home as much as possible. Occupational therapy can't make the most of that opportunity until it becomes a recognized qualified service.

ADVANCE will research this situation further before recommending action to readers. You can keep up to date at www.advanceweb.com/OT under Vision Center on the homepage. You may also reach me at ebrown@merion.com with questions or information.

E.J. Brown is editor of ADVANCE. <% footer %>