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How about a little game of word association?
Steven Tyler (Aerosmith).... foot surgeries.... rehabilitation facility
Poor Steven, the guy had to release a statement explaining that he isn't in rehab for drug substance abuse but is in rehab for physical therapy!
Apparently we have a missing identity for our role post-operatively. Hmmm...
Selena Horner
Costs.
In the last several posts, we have taken on the discussion of insulated idealists vs. practicing practitioners, the defending of PTA’s, and now payors.
I am suggesting that private practices take on an unholy alliance with payors. The reason is simple, they NEED us but they don’t have to have us.
Let’s imagine that all private practices are eliminated tomorrow (ok, I know, most of the population doesn’t know that we exist anyhow). Who will provide PT and at what will it cost payors?
Yes, it will predominately be hospitals who enjoy “most favored nations” status due to their strong negotiating leverage. The conversation typically goes something like this:
Hospital CFO: “I am the only center that can provide TURP procedures, therefore you have to give 90% on my grossly inflated charges for outpatient ancillaries”
Payor Exec: “Call it 85% and you have a deal” (never mind that this ends up being 2–3x what an outpatient private practice fee schedule looks like)
Hospital CFO: “87% or you get no TURP jobs”
Payor Exec: “Deal”.
Yes, folks, we are often referred to during these negotiations as outpatient “ancillaries”.
Before I get hate mail from hospital PT’s, please know that I have no inherent disrespect at all for hospital based PT. In fact, in 23+ years of being in this business I have worked in them, have had multiple contracts with many hospitals and joint ventures of all types and flavors. In fact, I think the best alliance is with private practices and hospitals.
Back to them NEEDING us.
If we are out of existence, their outpatient costs go up significantly and patient access is severely impeded (typically doesn’t matter to a payor I realize but in consumerism lingo does carry some weight).
Why do they pay us so much less? Because we don’t have leverage in negotiations and we don’t do TURPS or have inpatient facilities that payors have to have for their beneficiaries. We readily accept their fee schedules-even the absurd below the cost one’s. It is referred as “Limbo Negotiation” (how low will you go) and PT’s will go to unprecedented low levels to assure that they can see patients and under some false pretenses that they are being more “competitive” in the marketplace and doing “good for mankind”.
Ahh, but we do have leverage. Our existence! Payors will have much less margin if all of their patients go to hospital or provider based centers (those reimbursed like a hospital). We can leave “quality” out of this equation because this is never a concern to a payor. From their perspective, “quality” is like “common sense”-everybody says they have it but nobody can define it or prove it and even if they could it is an assumption that they already had it. Besides, PT is deservedly viewed as a “commodity”-undifferentiated in the marketplace (I would have said “widget’ but the analogy doesn’t hold up because widgets have consistency and less variation, something PT doesn’t).
In most supply chain management interactions between buyers and sellers, competition has forced a closeness to the point that the suppliers share their financials to the buyer. In my opinion that is how we need to think. We have to make sure that transparency exists so that buyers can keep us in business.
Some examples (just examples folks, not product or retail recommendations) from typical supply chain management:
Major auto manufacturers want to make sure that the amount they are paying their suppliers assures some margin. They argue of course over that margin but an auto company needs sustainable suppliers so they can complete assembly of vehicles to market demands. The Japanese in fact create incredibly close “family” relationships to their suppliers.
Walmart has to make sure that P&G makes a profit on Tide so that they can continue to sell it at a low price to consumers because consumers want Tide.
How does this fit into private practice?
Show them your costs-primarily labor (typically 70% of overall cost). PT’s are a well educated bunch and coupled with a supply demand curve just this side of the Wii, prices are up without concomitant rise in reimbursement. The same for operating costs and facility leasing (roughly 20% of revenue costs). All in all, costs in most locations throughout the US are going to be $65–80 per visit. If you want to get real specific, get a cost accountant but you probably don’t need to go to that level.
You can also point out the over regulated part of our industry driving costs up as well as the excessive amount of time spent in documentation and non-billeable services.
Costs of private practices are much less than our institutional counter parts-they almost always will be.
Will it work? Probably not but it is much better than accepting contracts below your costs-something that is very contagious in the PT world.
But, it worth a chance and if it doesn’t we might all just might be working for the Turp factories.
Thoughts?
I want to talk about EBP in a different perspective in this post. I hope it will generate some good discussion about the role of evidence, theory, and research in driving our practice and our therapy culture. My apologies in advance for the long post, but I hope you'll find it worth reading, thinking about, and commenting on. As a bonus, I promise to not discuss specificity, reliability, or analyses of variance or to end another sentence with a preposition.
In a recent series of blog posts on John Barnes' Myofascial Release, we examined that proposed evaluation and treatment scheme. During some of the discussions, a colleague posted this comment:
"Individual practitioner experiences would be level 5 evidence. That's great...but if we are to really see if MFR is a better choice of treatment than any other intervention or just the passage of time, then we need better quality controlled trials. Even a case series in a peer reviewed journal would open the door to a feasible discussion."
While I agree with what was said, it unsettled me at the time, and I had a hard time figuring out why. The next day, I posted this response:
"I think it's important to consider that, for MFR and most alt-med treatments, the "outcome evidence-only" brand of EBP won't get us very far - and in fact may set us up for trouble.
Let's say for example I publish an RCT showing that MFR produced clinically meaningful changes in an outcome measure of interest versus a competing intervention. Does that tell us ANYTHING about the truth of stored memories, fascial restrictions, or energy medicine? No. Success in the treatment DOES NOT validate the theory.
When I see my colleagues approaching alt-med treatments asking for outcome evidence, I get justifiably nervous - are they just one RCT away from believing in energy medicine? What we should be focusing on is the absolutely indefensible theory here - it's scientific reasoning that will help us here, not statistics. Let's never forget that."
Acquiring extra change ($$$) for delivering change in function should be simple. A patient will improve, not improve or worsen. Sounds simple enough. Is it though?
Of course, some type of measure should be utilized at baseline and then again later at various time intervals throughout the episode of care. Obviously, to interpret the difference in scores, statistics are required to define relevant change.
Various populations may have different figures for relevant change for the same measure. Take, for example, the Berg Balance Scale. If I interpret what I read correctly, knowing the amount of relevant change to determine outcome will be tedious. For the Berg Balance Scale, apparently a 2 point change for someone with Parkinson's disease is relevant; a 5 point change for older patients with or without a cerebral vascular accident is relevant; a 3 point change for patients with hemiparesis is relevant; a 4 point change for patients with traumatic brain injury is relevant.
The idea of acquiring extra change for delivering change in function is going to cost us our time and our money spent on technology to assist us in the process. Will our efforts gain us more than just a pile of change?
Selena Horner
- photo by Flickr renewleeds
I greatly respect the physicians behind this movement. Other than a few sentences and minor reworking, it is just as appropriate for PT’s. Perhaps somebody can do the edits. My favorite parts:
You are paying a lot for healthcare and not receiving enough in return.
Your insurance premiums continue to increase while your healthcare options are dwindling.
We believe the following factors have made our current healthcare system unsustainable:
The insurance industry's undue authority and oppressive control over healthcare processes
Excessive and misguided government regulation
They refuse to stay silent.
Perhaps we can pick up their cue.
Have a great Memorial Day!
Thoughts?
This is not a human rights post or meant in any way to attack any individual PTA working in the PT profession.
I know that I am going to get a lot of people mad at me, many of which are friends. This is not my intention. However, we have to get this issue out in the open.
Hopefully we can get “seasoned” PT’s (especially the balding and grey haired one’s), students, and PTA’s contributing to this discussion.
Questions, many questions.
How can the role of PTA’s within PT profession be defended?
How can the evolving nature of PT education go from baccalaureate degree to masters to DPT, yet PTA is still an associate degree? Basic math has their training at 2/7 of a PT.
How can salaries for PTA’s be higher in some markets than PT’s? CMS thinks we are in policy and reimbursement makes us equals.
Can the majority of tasks that a PTA perform be done by a technician without a degree?
How can CMS policy be so inconsistent with PTA’s? They grant them the ability to see patients without on sight supervision in evey setting but a private practice including their home? (isn’t there some type of statistic that more accidental deaths are done at a home than anywhere else?).
Why are they part of our national association? Are LPN’s part of the AMA?
I am not questioning the need for support personnel in a a PT clinic or the value of a PTA in terms of their ability to assist the PT. We greatly need them but their elevation ironically is hurting our industry thru pay scales and our inability to direct technician levels to a lower cost alternative due to the superimposed Medicare rules (of which some are trying to get other mayors to adopt) and other restrictions.
Many want to promote that PT is the exclusive property of PT and that services can only be rendered by PT or PTA. Why do we include PTA in the mix? If we make it exclusive to PT, we then can argue that supervision and delegation are the sole responsibility of a PT only within their scope of practice. Coding already is under a PT only responsibility. Wait, I just forgot all of those responsibilities are already the PT’s!! PTA’s have the best deal going outside of insurance CEO’s stock options.
From what I can tell, somewhere along the lines, probably because PT’s are such nice people, we legitimatized the technicians as professionals and came up with the brilliant notion that it is better to train somebody in a 1 year (I realize they go 2 but really only 1 is clinically oriented) community college setting than through on the job training. Perhaps it was manpower shortage-who knows. We also carried their banner to the federal government by getting them in medicare policy and then after various state gyrations of certification or licensure got them in the PT practice acts.
I have hear the argument that some have proposed that PTA’s are comparable to mid level practitioners-NP’s and PA’s. Bad analogy. NP’s and PA’s have advanced training well beyond a community college degree and are trained to be evaluators and screeners, not exactly legal in the PTA world.
What’s the answer? More school for PTA’s? Eliminate them from the lexicon? Make PT exclusive to PT?
Thoughts?
When one wants something SO badly but doesn't have the financial resources, one can get creative.
Apparently personal dreams can outweigh surgical risks.
Another example of Girl Power.
Another example of the power of the social internet.
Provide an avenue for social connections, let the women share their... stories, let the men put up their... cold hard cash, and allow the presence of cosmetic surgeons who will make those dreams come true AND collect the cold hard cash and what do you have? My Free Implants
Don't we help dreams come true too? Don't people want to be able to work and play during their day? Isn't it a pain to be in pain? The above exemplifies that women will go to great lengths to get what they want. How do we get women to want and request physical therapists?
Selena Horner
photo by FDA
One of the obvious benefits of this blog has been the strong discussion in the comments section of each post. Often comments go on and on, long after a post has been created. It is in these comments where ideas are shared and the pulse of our profession is truly felt. However, blogs have long suffered from comments that are difficult to follow once a long list of comments exist.
To that end, we've upgraded our commenting feature to incorporate those features that make a discussion board great. Namely, it is now possible to have threaded comments and choose to reply directly to any of the comments, or post a new comment in a different direction.
We're using Disqus, which also allows users to create a profile where your comments become more than an isolated thought on a single blog, but a networking tool, and a way to carry your professional branding from one blog to another. This is truly an upgrade to the blog and we're looking forward to even more enriching conversations. Leave a comment on this post to try it out and let us know what you think!
Look what turned up at the AAOMPT Student Special Interest Group Blog! I have a feeling this year's AAOMPT conference in Seattle is going to be a lot of fun...and incredibly important!
Good Work, University of Puget Sound Students!
Another great example of volunteerism by PT’s helping and caring in their community. Looks like done and provided thru oversight of the University of South Florida PT Program in Tampa, Fl.
I am a huge fan of the perspective, passion, volunteerism, and view of work/life balance of PT students throught the country.
The fact that they often get ruined (and ripped off for that matter) by the current model of clinical internship training is another matter and another post for another time.
However, there is more to evidence and to evidence-based practice than outcome studies.
Let's do a thought experiment. Let's say that tomorrow a large RCT is published on the treatment of thoracic back pain with JFB-MFR. As many of you know, we don't have much quality evidence to choose from in considering options for a patient with thoracic back pain - relative to cervical or lumbar region pain. Let's say this RCT found that the MFR treatment produced clinically-meaningful improvements in a patient-centered outcome survey and in pain rating scores. Would that give you any information at all about the truth of energy medicine, stored memories and emotions in the fascia, the applicability of quantum physics to patient care, or the validity of myofascial restrictions?
I would hope your answer here would be "NO!"
We see here that demonstrating that the intervention is effective does not do some of the hardest work that we need to do in science - it doesn't help us formulate a scientific theory or "deep model" that we can use to guide our practice and research. At the end of that notional RCT, we are no closer to determining why the patient got better than we were before we did the study!
You see, its a basic theory or deep model of function that underpins it all. It drives our education. It becomes part of our therapy culture. It's imparted to patients during treatment. We cling to it for support when we have a lack of outcomes evidence to guide us.
The late Jules Rothstein PT PhD, in one of my favorite editorials "When Thoughtfulness Dies", encouraged us to not just lob outcome studies at each other, but to develop a good theoretical base for our education, explanatory models, and treatment development. He even referred to it as a "secret weapon". I contend it's only a secret because we don't examine our interventions and teach our students the way other scientists do - we don't start with a sensible explanatory model or theory. It's at that level that JFB-MFR is dead in the water. An RCT would be a waste of time if the treatment makes no sense. That is where JFB-MFR and the alt-medicine treatments fail - at the basic level, they just aren't consistent with human physiology. Seen in this light, NCCAM could save a lot of money by requiring a good deep model from their investigators before throwing gobs of money toward outcome studies that somehow never seem to bear much fruit. Those who recognize the role of theory in practice are not surprised at this lack of success.We should focus as much on challenging our explanatory models and teaching in ways congruent with actual human physiology as we do on producing outcomes research, or the next generation of DPTs will be just one or two RCTs away from doing Reiki and Therapeutic Touch. Hey, if there's "evidence to support it", it must be good, right? Can you see the problem with outcomes-only evidence?
I can think of a few deep models in the therapy culture that haven't held up to examination, but that some therapists still cling to - and these false ideas still are common in our educational programs. I'm thinking of the disc model often referred to by some McKenzie advocates and the facet joint subluxation and motion palpation examination model often referred to by some in the manual therapy community. These deep models have been shown to be inaccurate, but they persist in part because some of the interventions that are thought to rely on them (directional preference exercise and manipulation) have good supporting outcomes evidence. These incomplete and inaccurate deep models, when kept in our therapy culture, keep us from looking for other explanatory models that still fit the outcomes evidence but that are more accurate. That updated deep model opens up new avenues for treatment and research. If those models aren't challenged and updated, we miss those opportunities. This is how science progresses in many areas - a constant reexamination of the underlying theory in light of empirical evidence.
What do you think about the role of theory in practice?
What would you say to a colleague who practiced based more on a solid theory than on outcomes research? Could that still be considered "evidence-based" practice?
Your comments are welcome.
-Jason Silvernail DPT