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Attached is a summary of the recent South Carolina Supreme Court opinion related to POPTS that was drafted by APTA and the South Carolina Chapter. We previously blogged about it here.
Have a great weekend!
John
Download SCAPTA-2006-09-28-bennett-statement-re-Sup-Ct-opinion_popts.doc
I have a patient I would appreciate some guidance on. Hx: 46 y/o male with chronic neck pain over past 2+ years. C/o pain primarily lower cervical spine, right greater than left, tightness in his neck and feeling of easy fatigue of neck muscles. Occasionally his sternocleidomastoid will go into "spasm", causing severe limitation in range of motion. Other symptoms he describes are ringing in his right ear, a "fullness" sensation of his right ear, right mandibular pain, occasional feeling like when his neck gets fatigued by the end of a long working day that his speech actually gets slurred. PMHX of high speed MVA x 4 years ago when he was broadsided by a car going about 50 mph, striking him in driver side door, totalled both cars. He had some neck pain after that, Xrays were normal, able to resume normal activity after a few weeks with minimal pain at that time. This patient was referred to me by his neurologist who has essentially given him the million dollar workup. CT Scan and MRI of his C-spine showing mild Degenerative changes C5/6/7 uncovertebral joints and facet joints bilaterally, mild neural foramen narrowing at C5/6, mild C5-6 DDD without nerve root impingement. He has had ENT consult for the oralfacial and ear symptoms with CT of his head, MRI of his brain, MRA of the circle of willis, all yielding normal results. His occupation is a pilot by trade, but he has been an administrative supervisor for past 5 years with minimal cockpit hours.
Exam: essentially normal posture, slight fwd head position. Good Cervical AROM in flexion, lateral flexion and rotation except tightness noted in his right upper traps during left sidebending, and right SCM tightness as well. Good strength bilat UE's, normal DTR's, normal sensation bilat UE's, normal facial sensation with light touch bilaterally. Moderately TTP to C5 and C6 Spinous processes and R greater than L transverse processes. Mild hypomobility C4-C7 with lateral glides segmentally bilaterally, although more painful and tender on the right side gliding to the left. Weakness in deep neck flexors with chin tuck and head lift maneuver, only able to hold his head up without losing the chin tuck for about 5 seconds.
Interventions so far: light chin tucks in sitting, chin tucks in supine using "The Stabilizer" behind his occiput for small changes in pressure, self upper trap stretch, self scalene and SCM stretches.
Manual therapy: The most puzzling part of the exam and intervention so far is that with a simple right sided upper trap manual stretch with contract/relax while depressing on the right shoulder I get reproduction of his oral facial symptoms of "fullness i his right ear", mild echoing of sounds in his right ear, facial pain along right sided mandible, and "fatigue" of his oral facial muscles, and one episode of right eye orbital pain.
I have done a literature search on ear and facial symptoms as a side effect of cervical manual therapy techniques and found the Cochrane review "A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders" by Gross et al. Spine: V29 N14/pp1541-1548, 2004, they cited possible adverse events including ear symptoms. But I found nothing to connect any of the mandibular pain from the trigeminal nerve.
I am concerned about vertebral artery insufficiency, but with the VBI screening test static positions there was not reproduction of symptoms or nystagmus.
Any recommendations for other workup for VBI that can be pursued? Imaging studies on the VB artery? Other interventions recommended? Other thoughts? Thanks!
Bob Wiederien, PT
Respect commands itself and it can neither be given nor withheld when it is due.
Eldridge Cleaver
By the way, happy Health Care Festivus. For those of you new to the blog, this week the federal government will not be sending out checks to health care providers for payments due them on medicare recipients. It is simply a way to save money. Yes, we still have to pay our bills and make payroll but that is besides the point from their perspective. If they did this to postal workers, members of Congress, Veterans, government retirees, you would have undoubtedly heard about it on the all major news network. Since we are health care workers, it isn't noteworthy. Neither is the impending 5.1% Medicare cut in fee schedule except to a few politicians concerned about their re-election.
Anyhow, from today's WSJ (article free for 7 days):
"The health-care premiums of employers and their workers have climbed twice as fast as wages and inflation in 2006 -- to nearly double their cost in 2000 -- and look to rise at a similar clip next year, two nationwide surveys show."
Average family premiums rose 7.7% in 2006. Although this is less then double digit rates than what appeared in 2003, it still exceeds inflation.
How many of our readership have experienced any rise in reimbursement to these levels? PT which generally represents from 2-5% of the health care premium dollar has been over-represented in cuts. Sure, we can set our pricing as high as we want but at the end of the day, we are at the whim of payors who have generally decreased our reimbursement or at best kept our rates flat for years. We are unfortunately in an industry that we can't pass our increased costs of doing business to our customers and that is about as worth celebrating as our lack of payments this week by Medicare.
Thoughts?
Larry
The South Carolina Supreme Court published its decision earlier this morning on the much anticipated case related to POPTS. The Supreme Court concluded that the South Carolina Circuit Court correctly interpreted Section 40-45-110(A)(1) to prohibit a physical therapist from working as an employee of a physician when the physician refers to patients to the physical therapist for services.
The Supreme Court also affirmed the circuit court's ruling that the Board's endorsement of the Attorney General's opinion did not constitute improper rulemaking; and affirmed the circuit court's rulings that this interpretation of the statue did not improperly infringe upon physicians' statutory right to practice medicine, violate Appellants' equal protection rights, or violate Appellants' substantive and procedural due process rights.
The decision can be read online at: http://www.judicial.state.sc.us/opinions/displayOpinion.cfm?caseNo=26209
Lisa Saladin, President of the South Carolina chapter of the APTA (SCAPTA) set the record straight over whether existing POPTS were grandfathered (which we had previously posted as being the case). They are not grandfathered. In her comment, she states:
"The South Carolina Supreme Court upheld the current law in SC that prohibits PTs and PTAs from working for physicians who refer to them. There was never a grandfather clause in the current law and the legal challenge never addressed a grandfather clause at all. All PTs and PTAs in South Carolina working in a POPTS are out of compliance with current law and subject to disciplinary action by the SC Board of PT Examiners. To our knowledge, the majority of PTs and PTAs in SC who were working in a POPTS setting have already worked out alternative arrangements. We view this as a very postive step for the consumers of our services and for the profession of physical therapy. On behalf of SCAPTA, I extend our sincere appreciation to everyone who has supported this effort."
This is definitely a great day for South Carolina. One question still remaining is what these 'alternative arrangements' look like. Docs are now doing deals with private PTs where they are overcharging for sq. ft. This technically is illegal but evidently quite pervasive. Regardless, an exciting day for South Carolina and the PT profession as a whole!
Any further thoughts on this ruling? It would be great to hear from blog readers in South Carolina. Feel free to comment about specific names of individuals in South Carolina to whom we should extend our thanks. Which state(s) are next?
John
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Hello all.
I just wanted to make you all aware of the fact that the latest issue of the Journal of Manual and Manipulative Therapy has been posted online at: http://jmmtonline.com/. For those of you unfamiliar with JMMT, it is the official journal of the American Academy of Orthopaedic Manual Physical Therapists and the Canadian Academy of Manipulative Therapy and it is read worldwide with subscribers in some 40 countries. Our goal is to provide up-to-date, evidence-based, clinically relevant information in the area of orthopaedic manual therapy.
Referring back to a comment John had made with regard to JOSPT, despite our diminutive size compared to that journal we manage to get our issues online before the hardcopy even leaves the printer. Since I have become the Editor-in-Chief, we have also increased our open access and open access, online-only content in an effort to disseminate the material published even wider and quicker.
Open access material in the latest issue includes the abstracts for the upcoming AAOMPT conference, a great guest editorial by Dr. Gwen Jull on cervicogenic headache diagnosis, a case report by Paul Glynn and Josh Cleland on the evidence-based management of a patient with neck and upper extremity complaints with online video supplements, a research article by Oostendorp et al discussing possible characteristics of subpopulations of patients with so-called non-specific low back pain, and a case report by Schenk et al on management of a patient with cervicogenic dizziness. The subscriber-only content is equally interesting and --in my admittedly biased opinion-- well worth a subscription to the Journal.
I would like to invite you all to visit the website and review the material freely accessible. I also hope that this material might stimulate some discussion on this weblog: discussion is a good thing!
Peter
Two important events occurred over the past few weeks that should not go unnoticed. First, the inaugural conference for the NIH funded PROMIS project on patient-reported outcomes (PRO) was held in Gaithersburg, MD, and second, Representative Wilson from Albuquerque, NM introduced HR 6048 entitled “The Medicare Outpatient Therapy Value-Based Purchasing Act of 2006”.
The PROMIS project is part of the NIH roadmap for medical research where a multi-faceted, multi-site project is underway, the results of which may well be the replacement of our current outcomes measures with new PROs developed using Item Response Theory and administered using computerized adaptive testing (CAT) technology (http://nihroadmap.nih.gov/clinicalresearch/promis.asp). For those of us in the measurement world, that is exciting news! For those dedicated to traditional instruments like the Oswestry and Neck Disability Index, you may want to rethink your psychometric allegiances. At this time, no one knows where the PROMIS project will take us, but the research team is developing and using standards for measure development and application that will set the tone of measurement for future clinical trials and clinical applications for years to come. I think it will be an exciting ride!
On the second front, the pay-for-performance or value-based purchasing movement at CMS and other payers is alive and well. Rep. Wilson’s bill, like so many other legislative efforts, faces an uncertain future, particularly in an election year. However, the bill will probably set the foundation for future P4P efforts or bills. Regardless of the fate of Rep. Wilson’s bill, this legislation may well be the beginning of a new payment structure for clinicians in outpatient settings. As mentioned by Tony Delitto (JOSPT 2006;36(8):548), why not hold the clinician accountable for their patient’s outcome? P4P bills might start by “paying for reporting” as an initiation into the value-based purchasing process. Structure as well as outcomes measures may very well facilitate use of evidence and practice guidelines. Hopefully, the guidelines will be based on evidence (i.e., did the patient get better, not consensus), and hopefully, electronic health records that are integrated with electronic outcomes, like those generated using CATs, will become the norm. In our CMS funded P4P work, we hypothesized that clinicians using evidence-based practice stand the best chance of producing better than predicted outcomes with fewer than predicted treatment visits, if indeed evidence-based practice leads to better outcomes efficiently. If payers reimburse providers on efficient outcomes, good providers should get the best available payment.
Obviously, again, no one can predict where the P4P movement will take us, if it will take us anywhere, but we are positioned at this time in history to move the profession forward because of three facts. We have more and more clinicians clinically and academically skilled in the use of evidence-based practice methods, so they will use them now and be able to adapt rapidly when we learn more. We are improving the measures used to quantify our outcomes and the methods needed to risk adjust our outcomes. The payer will demand different payment strategies that may even reimburse the provider for efficient outcomes, which will usher in a dramatic change in practice management. I for one believe we are ready to start.
Download Medicare_outpatient_value_purchasing.doc
I guess I deserve it. Since I post quite a bit about CMS, several subscribers saw fit to email this proposed legislation HR 6048 The Medicare Outpatient Therapy Value-Based Purchasing Act of 2006. This is not to be confused with other possible legislation including the Barton legislation which would possibly increase the fee schedule .5% for three years instead of the impending 5% reduction (provided that providers succumb to a utilization management program).
The document for you to download provide an excellent executive summary (undoubtedly not prepared by the famous CMS PR team).
The attempt is to compensate providers of PT, OT, SLP based on effectiveness of care. Per the summary, the legislation would encourage providers of therapy services to provide the highest quality care in the most efficient way possible, using evidence-based methods of rehabilitation (evidence based is not a misprint). In this legislation, therapy providers would be compensated based on their performance compared to national benchmarks for a given condition, eliminating the need for the Medicare therapy cap.
The bill calls for implementation in 2010 and a transitional program eliminating the therapy cap for providers who participate voluntarily before 2010. Quality measurements would be stored in a national database and available to the public so consumers can make informed decisions when choosing therapy providers.
Regardless of whether the bill has any chance, you have to applaud the efforts to 1. come up with an alternative to the Cap which is supposed to happen but we are seeing very little suggestions and 2. Use evidence based methods of rehabilitation.
Larry
Has anyone read anything on this settlement? I try to stay current with 3rd party payers and was surprised that I received something in the mail. The APTA was listed as an organization that settlement funds could be contributed. I couldn't find anything on the APTA site and I haven't received anything that I can recall from the APTA or the HPA listserve.
I don't know enough or understand enough about settlement classes and was wondering if someone could enlighten me. I would definitely like to be a part of a group attempting to put a stop to some of the "games" that happen with reimbursement. The fancy words of attorneys summarize the case as basically Humana, its affiliates and a few other defendants as "engaging in several types of allegedly improper conduct." I definitely dislike it when third party payers perform the actions specifically listed, but as one provider, one provider can only fight the fight and never get anywhere.
Lots of legal and formal language at www.humanaprovidersettlement.com
Does anyone have any insight?
