The Most Important Issue in the PT Profession.

And I really mean it.

There is a raging debate within the PT profession. Over past several weeks, I have seen it as part of many discussions and it was recently manifested on a PT listserve of the administrative section of APTA. I know that listserves are “old technology” but it actually works well for PT’s who tend to be slow adapters and certainly if it isn’t broke, don’t fix it!

The debate is centered over a seemingly growing movement that unfortunately has far reaching consequences: Do all services rendered within a PT clinic have to be one on one and performed by a PT or a PTA (I personally would prefer to leave the PTA out of any discussion but since medicare in much of their policy implementation makes us reimbursement equals, I will include).  The debate unfolds something like this:

The Players:

Practical Practitioners:  PT’s mostly who are in private practice or typically on a day to day have some encounter with the repercussions of the economics of their practice. If not in private practice, they oversee a department or a clinic and its financial performance and thus are faced with reimbursement realities, compliance, and trends and the pressure to keep their department or facility above water.

Insulated Idealists:  PT’s in the industry who don’t practice at all (e.g. some academics), or who make their living not in PT practice but in lecturing to PT’s on reimbursement or coding, most members of the federation of state boards, or PT’s who are in a niche industry (e.g. they do 100% cash Pilates) that is grossly atypical and misrepresentative of the overall PT sector.  The bottom line on these idealists is that at the end of the day they never are faced with the real world difference between the service of PT and its financial viability.

The Debate:

According to the Insulated’s, 100% of all PT has to be done one on one by a PT or PTA without exception and to do anything to the contrary is fraud and should be punished by jail, fine, license revocation or preferably all three (truth be told a few canings ought to be in there as well).  They believe that Medicare superimposed rules are the best thing since the Wii  and that the CPT codes by definition further support their position and every attempt should be made to gather national payors to get their acts together and adopt medicare as the de facto standard and in addition open up every practice act in the US and amend those to be of the same standard and consistency in every state where their position is duly reflected. 

Iinsulateds believe that nothing should every be left to the judgment of a PT but rather every possible clinical scenario  and intervention should be explicitly listed and reflect that it has to be done one on one PT or a PTA.  They frequently site the excessive use of techs and aids in PT departments.  For the PTA, they typically suggest that the PTA is duly licensed and essentially the equivalent in every way except for evaluation, manipulation, and debridement (some Insulateds would point out that an advanced PTA can perform the last two).  Even a hot pack that nobody pays for has to be applied by a PT or PTA.  In there world, nothing is left to chance and the list of rules for PT and practice acts would be about the same size as Tolstoy’s War and Peace.  Economics is never considered because their fundamental belief is that PT ought to be free anyway and that any PT who makes more then them is a greedy crook who only looks at money.

On the other side is the Practicals.  They believe that medicare superimposed rules are stupid and that although you have to follow them that every attempt should be made to get rid of them and more importantly stop the madness from methastasizing to other payors.   The Practicals believe that a PT’s education and practice act allow both delegation of care and supervision in accordance to their judgment as a PT. They believe appropriate checks and balances are in place to prevent the excesses and avoid the impulse to manage to the small percent of PT practices that abuse the rules. Practicals look at the CPT codes in the same manner that physician’s-unless explicitly stated, supervision of support personnel thru delegation and direction aptly meets the description of the code even in cases where the word “one on one” is used as long as the one on one by a support person is done under supervision as outlined in their state’s practice act.

Relative to Vision 2020 Practicals actually buy into it and see the attempt by Insulateds as de-evolutionary to the profession. Practical believe that the Idealist’s view of Vision 2020 is illusionary. They believe Insulateds don’t see how their position runs contrary to a direct access practitioner who is autonomous  Practicals take the position that a doctorate degree with advanced clinical training is best positioned to make judgments within the scope of practice of what their support personnel can do in much the same way that you see physicians manage their nurses and techs.

Practicals both laugh and are incensed by the Insulated’s activism toward amending practice act and attempts to make all care explicit.  A practical would ask “do you see physicians trying to eliminate their nurses and support personnel from their supervision?”.

Practicals are faced with the financials repercussions of not taking certain contracts or the difficulty of trying to align quality care in a declining reimbursement arena by applying appropriate resources in conjunction with the insurance that patients have.  Practicals site the great success of the military and VA system who have empirically shown their cost effectiveness in an environment where reimbursement is not an issue and where the PT is given significant autonomy and unfettered supervision over their techs and support (and at least the case in the military prescriptive authority and ability to refer for imaging).

Practicals would like to debate eliminating PTA’s from the profession and site the drastic educational differences and the inconsistent Medicare policy towards them.  Any attempt to align a PTA as equivalent to a PT is appalling to a Practical.  Practicals also site that evidence does not exist to support any of the condescending positions taken by the Idealists and that the free market thru both quality indicators and consumerism will determine the most efficacious delivery of PT.  Practicals believe that PT can be economically viable if the shackles of the regulatory environment were lifted and the idealists would halt their ways in attempting to further restrict the profession from becoming autonomous providers.  Practicals believe that without margin their is no mission and that without economic viability that our best and brightest will not seek out a PT career and that we will quickly head towards a 7 year degree getting $27 per visit for one on one care with more loan debts than a third world country.

I don’t think you have to guess which side that I am on.

The Question:

Which side are you on?  Who is winning?  What are the implications of Insulated’s position for the future of PT?

larry@physicaltherapist.com

Comments

[PaulS]

Just last night, after a competitive recreational sports competition, I met with a fellow provider. He was grouchy; stating “I hate health care. They want us to work for free. I got a buck fifty in loans, and they keep infringing on our practice. I work in three cities; try to go where the action is. Nurse practitioners, PA’s are doing what I used to do. We have no professional representation, no unified advocacy, and our patients aren’t really concerned with how much we get paid, just to see that they don’t have to fork out too much out of pocket.”

I was talking to a practical practitioner to be sure; dare I mention he is a podiatrist. But the similarities resonate. Interesting how your post today mimics what we spoke about last night.

Our professional associations (PT and Podiatry) appear to be led by idealists. Those idealists would like us to spend more time lengthening the content of our notes and redefining how we treat document. Since payment and reimbursement appear secondary on the agenda, we will get paid less for what we do, but revel in the fact that although we spend more time writing about it, the note will look fantastic in the eyes of the idealist. After seven years, we could burn our old documentation to heat our clinics. That is, if the doors are able to be kept open for seven years in the face of increased competition, decreasing payment, and other obvious issues that are obvious enough they need not be mentioned.

A few months ago, I met with a minister for an informal chat about our professional development pathways. He shared his thoughts on the different types of doctorate available to those who spread the Word, and I tried my best to explain the different types of Doctors in the PT profession. We competed to see which made less sense, and it truly was a tie, or we both lose. Alphabet soup dominates religion as well as Physical Therapy. None of it makes sense.

His doctoral dissertation was going to be on what he thinks will be a negative correlation between education level of a minister and the ability of that minister to relate to the average Joe. That is, the more educated your minister, the less they relate to the average person. They no longer can relate to their ‘customers.’ They lose touch. His catch phrase is that you just have ‘lunch with truckers.’ And I believe that phrase would apply to the APTA. They need to have lunch with, well, those PTs who honestly are at risk. I am talking about the PT who needs to render a certain # of the aforementioned CPT codes in a given clock hour or calendar day in order to offset the rising costs of keeping the lights on during the day and the doors secured at night. The idealist needs to spend more time meeting with those PTs.

Thanks for bringing this up.

[Selena Horner]

Larry, it's even more than idealists vs practicalists. (Is that a word?)

I would be willing to bet that the majority of those in our profession have no clue any of the business aspect. If the majority have no clue, then that means that there will never be enough energy or concern to create change. The wheel will never get squeaky enough.

As a whole, our profession is reactive versus proactive. By the time a reaction occurs, often times it is too late to reverse whatever ridiculous regulation. Yes, there are some definite proactive therapists, but the problem is the poor proactive minority continually hit a brick wall.

It is mindboggline what the future might hold... from a Medicare perspective (since that seems to be the most transparent payer) - reimbursement is going to continue to dwindle due to not enough financial resources yet at the same time due to the growing population there is concern that there won't be enough professionals to care for this population. Where is the incentive to care for this growing population when payment sucks, the regulations are not conducive to business longevity and professionals are treated like kindergartners?

[Christie Downing]

Does anyone really think that medicare regulations are the greatest thing since WWII? If so, they need their head examined. However, even as I (I will term myself a practicalist)am the first to say how increadibly wasteful and illogical some rules are (can anyone REALLY tell me why we need to fill out the medicare secondary payer form every month? I mean c'mon...is someone who didn't have black lung benefits one month REALLY going to have it the next?)some medicare regulations were necessary. Yet, I think this mainly effects hospitalization where fee for service was an incredibly inefficient concept ($12 for a 4 x 4? Really!)PT was unfortunately targeted. Yet, hasn't it allowed us to really look at how we were practicing? Haven't we become more efficient providers since its implimentation. Although we loathe the insensible regulations (which probably actually cost the system more in the long run), hasn't this lead to a wealth of VALID research that increased tenfold (my estimate here) since these regulations were implemented? We've really become better professionals since the new regulations (or should I say "inspite of").

Another point I'd like to comment on is the persuit of the doctoral degree and while we focus on how it will affect our profession, are we leaving our fellow PTAs in the dust? Everyone focuses on how it will affect US, direct access, patient care, etc. Yet, if WE are going to accept more responsibility, shouldn't the people to whom WE delegate also contiue the progression of their degree? Have you (anyone) ever looked at the educational requirements to enter a PTA program versus a PT program? I would contest that we need to further progress their degree as well...gross human anatomy would be a good start! Furthermore, there needs to be a more logical "stepping stone" for PTAs to transition to a PT degree. At this time, there are only two "bridge" programs in the US; and really, it doesn't give the PTA any credit for what they've learned already. They must start at square one like every other undergraduate. The only advantage the bridge programs offer is that it can be completed in a part-time format. I counsel so many prospective PT students online who think that they can become a PTA and then just "take a couple more classes" to become a PT. They are shocked when I tell them they are in for about 6 more years of education after their associates. After all is said an done, we must remember that PT was once a certificate program...we've had the chance to progress, why not PTA's? A.S. in nursing can trasition to a BSN, and BSN can transition to NP. Why aren't we following the progression?

As a practicalist, I see the benefit of utilzing our services as a resource. The more efficient we can be with that resource, the more people we can serve. If that means delagating to a PTA, then so be it. If that means we need to carefully evaluate what is really "skilled" PT, then so be it. Let's eliminate the fluff from our practice and make the most of it!

[John Ware]

The fact that such a distinction between the practicals and insulateds exists in our profession-which I agree with Larry that it does-begs the question, Why?

Without getting into the morass of our over-priced higher education system, which due to government tampering has totally skewed economies of scale, I think the intra- and interprofessional strife that exists in health care can be traced back to a reimbursement system that does not reward results. All of our ills in terms of finance and economics in PT and health care in general, all the turf battles, referral-for-profit schemes, practice-scope trespass, regulatory limbo, etc. come back to that fundamental lack of any semblance of a free market. Many, if not most, in the hallowed halls of academia, as Larry alluded, believe that people should not have to pay for their health care. At least in terms of health care, they are socialists. They think Medicare works just dandy- that it’s a model of efficiency, oversight and regulation, and keeps us all honest and on our game.

That belief, of course, is such a load of crap, and so mindlessly out of touch with reality (America is a capitalistic, free-market economy last I checked) that it makes me wonder what planet the people who hold this belief are from. When you ask these people, “Well, then, what are we going to do when Medicare goes broke in 15-20 years?” To this question, they glaze over, repeat the socialist mantra of how important it is that civilized countries “care for their sick” and throw in a couple of inane analogies with Canada and Sweden (whose health care systems and governments are also going broke). To top it off, they’ll America bash with statistics on infant mortality (whatever that has to do with health care), hospital accident rates (which are appalling), and the EVIL pharmaceutical companies' profits.

I believe this blog and EIM, if I may be so presumptuous, developed out of the angst that we, as PTs, feel over the ever-mounting tide against us to make a living and do the jobs that we love to do. This has been an admirable effort to bring us together to discuss and share what works, how we should be practicing, and, perhaps most importantly, to get a grip on the values that drive our profession. At times that angst and eagerness to overcome an entrenched, quasi-socialist system has driven the discussion perilously close to the edge of civility and reason (we have regressed to naming a colleague “whore of the month” for chrissakes!) I have on more than one occasion ranted like a banshee at this site, and then, when the dust lifted from the keyboard, asked myself, “Where the hell did that come from?”

The elephant, friends, isn’t just in the room, its big ass is sitting right on us squeezing the living breath out of us all. If we don’t start working together to get a grip on what kind of health care delivery system we want and within what economic framework, then the relatively few of us who are willing and able to mount the Herculean effort required to keep our profession alive will finally expire and explode under the pressure.

[Rod Henderson, PT, OCS]

Another outstanding post Larry and good comments that follow. I have difficulty understanding the idealism that pervades many in our profession, but I feel equally confident sites such as this and the dedicated few can keep the idealists at bay. I think it makes a stronger case for those of us "in the trenches" to become or remain active in policy making within our profession. This is something I took lightly early in my career, but will not continue making this mistake. Thanks for bringing this out and keep up the good work.

[Selena Horner]

Christie... Could you expound upon your statement that insensible regulations have led to a wealth of valid research since these regulations were implemented?

Do we have research that supports only one-on-one treatment? Are we sure this IS the most effective scenario?

Do we have research that clearly indicates that watching a clock and documenting the total timed codes AND total treatment time is efficient?

Do we have research that really supports that a PTA needs a PT on-site to supervise but a PTA doesn't need a PT on-site to supervise during home care?

Have you seen research that indicates we are more efficient because of a cap (of course there should be outcomes too just so we know a patient wasn't prematurely discharged)?

Oh, but wait... is there REALLY a cap - there is an exemption process - so is this regulation more of a "game" to see if we remember to add a KX modifier to our claim lines?

Oh, AND are you sure the regulations increase efficiency? IF a claim is denied, doesn't that mean there is some inefficiency where it has to be resubmitted and THEN it's paid? It's almost more like asking for an extension for payment but not paying interest.

AND... it's okay for payers to just take a break and announce that no payments will be made for a defined period of time?

I could go on, but I'd really be interested in the research that has come out to assist me in being a better clinician that supports the above regulations.

Also, I never fill out some Medicare secondary form. (Since when is it only MY responsibility to know what the heck insurance a patient has anyways? Ludicrous.) Technology is such that when one checks into eligibility and benefits, it is very, very clear if the person has Medicare as primary OR no Medicare benefits at all and has chosen an HMO or Advantage program. Also, just a heads up to you... if Medicare IS secondary and not primary, generally, you'll get a denial for your claim submission. Medicare knows who has benefits. You'll only see glitches if the employer doesn't communicate to social security (and that issue is on the end that Medicare is not up to date on information and doesn't have the beneficiary as primary).

In regard to your doctoral degree comments... nothing like spending a load of cash to then come out in the real world and be treated like a kindergartner.

I do not see prpofessional positives with the rules and regulations we are required to meet.

[Larry Benz]

Christie: you raise some great points regarding PTA's and their education (I think there are lots of other reasons to the issue but will leave it for another post at another time). I also agree that in general, compliance has improved the industry-however, it has now gone beyond a "slippery slope" with incremental compliance issues now causing ruin and significant increase in cost (worse really than a decrease in reimbursement). The best example is the myriad of technical compliance issues caused thru medicare compliance. This monitoring cost adds significant process, payment delays, and paranoia that saps the joy out of the profession. Idealists want to deploy those same rules to all national payors and furthermore won't really be happy until every PT wears a stop watch across their neck to go along with their goniometer and reflex hammer. What goes largely unrealized is that this approach to stop watch therapy puts a cap on a PT and a PT clinic's earnings and history is replete with examples of the ills of price caps. One need to only run the numbers of the amount that a PT can generate under the scenario that 100% of their patients are medicare (not a totally unlikely scenario).

John, your presumption is right on. The EIM blog and company was formed out of a total angst with inconsistency and variability across all parts of the PT chain.

[Christie Downing]

Selena,

You certainly pose a lot of valid questions...some of which I do not have the answers to. Yet, let us take a look at what the PPS system has done for our outcomes of joint replacement surgery. This is where numerous studies demonstrate the benefit of a different level of care than what we previously BELIEVED to be optimal(primarily focusing on the switch from inpatient rehab to home health). This is probably where the evidence is the most obvious to support my point. There are numerous studies including:

Chimenti CE. Ingersoll G.

Home Care of Rochester (HCR), 85 Metro Park, Rochester, NY 14623; cchimenti@hcrheath.com.

Comparison of home health care physical therapy outcomes following total knee replacement with and without subacute rehabilitation.

Journal of Geriatric Physical Therapy. 2007; 30(3): 102-8. (24 ref)

Collins T. Herness J. Martenas J. Roberson A.

University of Scranton, Department of Physical Therapy, 800 Linden Street, Scranton, PA 18510; collinst2@scranton.edu.

Medicare Prospective Payment before and after implementation: a review of visits and physical performance among Medicare home health patients after total knee replacements.

Home Healthcare Nurse.
2007 Jun; 25(6): 401-7. (14 ref)
HOME HEALTHC NURSE. 2007 Jun; 25(6): 401-7. (14 ref)

Oldmeadow LB. McBurney H. Robertson VJ. Kimmel L. Elliott B.

Physiotherapy Dept, The Alfred Hospital, Commercial Rd, Melbourne 3004, Australia; L.Oldmeadow@alfred.org.au.

Targeted postoperative care improves discharge outcome after hip or knee arthroplasty. (Although this is an Australian study, their use of specific functional goals resulted in good outcomes prior to D/C)

Archives of Physical Medicine and Rehabilitation. 2004 Sep; 85(9): 1424-7. (9 ref)

Kelly MH. Ackerman RM.

Orthopaedic Clinician, Shady Grove Adventist Hospital, Rockville, Maryland.

Total joint arthroplasty: a comparison of postacute settings on patient functional outcomes.
Orthopaedic Nursing. 1999 Sep-Oct; 18(5): 75-84. (21 ref)

Across multiple disciplines, we've been forced to look at how we were practicing...we continued on with the notion that inpatient rehab was optimal for good outcomes after knee arthroplasty. We've now found that to simply not be true for a certain portion of the population. I can only assume that this has resulted in lowered costs , but honestly I do not have the studies to back that up.

My point is, look at where the profession was just 10 years ago...or even five years ago. How many people were out there
were treating all your patients by throwing every treatment in the book at them? How many patients just 10 years ago were receiving heat, massage, and/or manipulation, ultrasound and 20 exercises that they could really being doing at home? Why are we focusing on "scapular" control for rotator cuff problems when the evidence for this frequently demonstrates that we can't even agree on if it's impaired or not? Why are we giving someone 10 or 20 exercises to do in the clinic when they need just one? Let's look at achilles tendonitis...research is now demonstrating that we don't need rest, stretching and US, we need frequent progressive eccentric loading...much of which can be done at home with follow up only to progress the program.

We've been forced into the position to really examine our practices to determine what is really efficient and what is not. We've certainly got a LONG way to go to catch up with the rest of the medical community. I still believe that less than half of what our profession does is really validated. Yet, I'd like to think that this position in which we've been thrust has helped us to become better and better faster in the last 10 years.

As far as some of the other issues you mentioned such as one on one versus a multiple patient approach, I do not necessarily support medicare's approach to THIS. Do we really need to sit there one on one with a patient as they work on the bicycle? Wouldn't medicare be pleased we are trying to be more efficient by trying to see more than one patient at a time? Although I am fortunate to work in a clinic where we do see patients one on one, I definetely realize there are cases where this is not necessary and only wastes a valuable resource (us).

Maybe I'm the only one that sees the benefit of what has been thrust upon us. Although I don't agree with many regulations that have come down (in fact, I think many of them are downright STUPID), I think we've become better professionals because of it. It's my silver lining view.

[John Ware]

Christie,
My question for you is: At what cost to the physical therapist and practice owner have the Medicare regulations and requirements been imposed? And furthermore, are the costs reasonable?

The byzantine, convoluted and ever-changing nature of the regulations that Selena has referred to require superhuman effort to uphold. PTs happen to be just the patsies that the federal government just loves to tell to "jump" as we ask "How high?"

In my opinion, more in spite of the regulations than as a result of them, we have become more efficient and focused in our treatments. Otherwise, the government would have run us all out of business after the 1997 balanced budget ammendment went into effect in 1999, and we'd all be working for the government in VA facilities around the country.

Our motivation is one of fear, not of inspiration to innovate-as occurs in an industry that is driven by free-market principles. Fear can be a good motivator initially, but after a time, it becomes demoralizing, and I think that's where we are now.

Meanwhile, our fellow colleagues in academia continue to beat the drum of more supervision for PTAs, more education for PTs, more refinement of the CPT coding system, more specific documentation of the treatment visit, ad nauseum.

I'm going to give you my answer to the question I asked at the beginning. The costs to the individual PT practitioner have grown WAY out of proportion to our pay scale and the myriad other non-compensatable factors that we are forced to deal with on a daily basis. What price tag do you place on educating a patient on whether or not they qualify for a KX modifier? Why should I have to vouch for a diagnostic rationale that has no rationality? Why is the federal government forcing me to lie for them, just so I can continue to see a patient who needs more PT?

More questions, I know. The elephant likes to ask a lot of questions while he bounces up and down on your chest.

[Larry Benz]

AND we are about 2% of the medicare outpatient expenditures. AND slightly less than 10% of beneficiaries access PT on an annual basis. We are very CLEARLY the most over regulated medical professional when viewed from that context. Unfortunately, it is not going to go away anytime soon and the Insulated's thru their cluelessness want to make medicare the standard for all national insurances and thru their aggressive work on opening up state's PT practice acts throughout the US. We have met the real enemy and it is our own profession.

[Selena Horner]

Maybe the reason we are over-regulated has to do with the simple fact that payers know that the probability that we would all just walk from ridiculous regulations is very low. If I were in their shoes, I'd do the same thing... go for the throat of the weakest link. Our services may only represent 2% and may only be utilized by 10% of beneficiaries, but cuts here and cuts there add up AND creating ridiculous regulations that might not always be followed to the "T" and hiring contractors to review claims/documentation obviously sets the tone that the regulations are meant to be revenue generating through penalties/fines and extrapolated take-backs. Obviously they don't care about the quality provided and the patient isn't interviewed to assist with determining anything. AND paying the contractor a percentage for erroneous claims can be very motivational. It's all about money.... AND it is a vicious circle, there are those among us who PROFIT off this ridiculousness because they go around teaching courses so we are shaking in our boots becoming ever so compliant. The regulations have nothing to do with the quality of care - bottom line is money.

Christie, you put a lot out there, but none of which you put out substantiates your claim that insensible regulations have led to a wealth of valid research. The reason you aren't able to come up with anything for my questions is because there is no research that supports those regulations. The regulations were not implemented based on any research nor has any research supported the benefit of those ridiculous regulations.

[Shawn]

So, let me take out my crystal ball... Medicare cuts are going to continue. There is going to be a huge effort to control costs throughout healthcare, Medicare and otherwise. Because of cost controls at the governmental level, treatments being performed by PTA's and aides are not going to disappear. It doesn't matter whether idealists and practicals agree. Economics will dictate parts of therapy are performed by lower cost labor, and a growing demand for therapy services among Medicare beneficiaries will ensure the government can't cut payments so deeply that it drives PT's away. In other words, politicians will respond to the demands of their constituents, and ensure our field doesn't die, (How do you think we got the exceptions process anyway?) but will keep it from flourishing as well. There will always be the tug of war between idealists and practicals, but the politician will "unlevel" the playing field whenever needed.

But wait, a second picture appears. In order to cut costs to physicians, direct access will be allowed, but only on a limited basis. More ineffective regulation to control fraud. Can we compete with Chiropractors and massage therapists as the people to see for 1 or 2 visits for aches and pains? Those that can will survive and flourish.

So, think my crystal ball is accurate?

[John Ware]

Shawn,
Unfortunately, I think your predictions are accurate, but I think you under-estimate the influence the academics/insulateds have on the reimbursement and regulatory climate that we're currently subjected to.

First of all, they are the one's indoctrinating our future colleagues with the rose-colored goal of a universal, government- payer health care system. Therefore, they come out of school with this skewed reality, and it takes them often years to get a grip on the real world of physical therapy practice. Secondly, the Insulateds are disproportionately politically active relative to private practice owners, who are so busy trying to meet regulatory requirements, run a business and find and keep good PTs, that political advocacy often doesn't reach their inbox.
Therefore, legislators get a mixed-message about what PTs value. The most common complaint I here from legislators is how garbled and disjointed our message to them is.

I don't think we'll ever change the spots of the "true-believers", who are hell-bent on a government-payer system, so we shouldn't waste our time with them. The problem lies with the scores of staff PTs who are totally non-engaged in the process of change. And that change has to begin with the way you practice, i.e. understanding and using best evidence. Then follows an effort on the part of practice owners to tie use of EBP to rewards for superior outcomes and efficiency, which should result from the implementation of EBP.

I think the true idealists are here at this EIM site. The insulateds that Larry refers to are in large part a bunch of cynics who don't think an adult person can make their own decisions about their health care- that they need the government to tell them to take their medicine, go to their doctor for an annual physical, have their cholesterol and BP checked. That's not idealistic, that's paternalistic.

That's not America.

[James Glinn]

Hi, my name is Jim Glinn and I am Practical Practitioner.

Larry, great post! Yes, yes, yes. I agree!

Let me also note that I am for sure in agreement with most all that John Ware writes as well. Great comments John!

Yeah, the whole thing is kind of silly isn't it? To have such a huge rift in our profession does not make much sense??

I want to hear from someone that is an "Idealistic Practitioner." Not so I can beat them up becaause I feel that my view is so coorect that all others must be wrong, but rather so I can figure out where these people are coming from?

What am I missing. Is there some sort of collateral damage possible if we have the autonomy to decide who assists us in delivery of care.

Is it because you feel there should be no "profit" in PT? If things continue as they are, that should take care of itself....

Maybe you feel that there is no way a PT can utilize care extenders like surgeons and other specialists??

Where are you Idealists?

Show us what we are missing.

[Laura]

No one will admit to being an idealist. If any of you know people who work in academia SOLELY and have no contact with clinicians whatsoever, ask them what they think that we (practicing clinicians) make per year, much less per visit. See what they say - answers may shock you.

I'm with you on the practical portion Larry!

[Christie Downing]

You're missing (or misunderstanding) my point, Selena. The point wasn't to insinuate that there is research that SUPPORTS those regulations , rather that with our backs against the proverbial wall, we've had to prove what we do as a profession is VALID. Is it a link directly to Medicare regulations? Not necessarily. The point is, look at how we've become more effecient and cost effective in the last 10 years. Maybe the causal link isn't direct, but I still like to think we've become more efficient in the past 10 years in our evaluation and prediction of outcomes, etc in the last 10 years during the time that these regulations have come down...and I think that research supports that just fine. I question whether we would have continued to evaluate the validity of our practice and modify how and what types of assessments or treatments we do if we weren't forced to deal with less. Rather, I'm sure many of us would've been content to keep practicing how we were since no one was questioning it. In the example I used above, I'm sure we would all have been content sending all our patients with post op joint replacements to acute rehab because we simply "believed" it would result in better outcomes (and believe me, that is what was happening at our facility before PPS came along). We now KNOW better. THAT is what the examples of my literature review support...that we now know better.

I cannot find any other period of time in the literature where we've come up with more validation for what we do as practicioners (globally speaking)as compared to the last 10 years. But NEVER did I insinuate that the research SUPPORTS regulations. Again, rather, possibly because of the regulations, we've been forced to become more VALID pracitioners...and to prove our VALIDITY is s good thing.

[John Ware]

Christie,
Given what you just stated about the regulatory climate essentially forcing us to prove our worth, I'll ask again: Do you think it's been worth it for us as professionals? Do you think PTs need to fear retribution from some government agency in order to prove our value? More importantly, do you think the government's efforts are noble and have our patients' best interests at heart?

The last 10 years since the BBA and PPS have been a perversion of the way the market is designed to work. I've already listed several of the "side-effects" from government tampering in the financial workings of health care delivery in this country. If you threaten people with fines, jail and bankruptcy, AND you have the power to impose all three, of course they'll submit. What's the alternative, take up arms and overthrow the government?

I hope you and other PTs out there realize that we have the wherewithal, each of us, to be excellent at what we do without CMS constantly holding our feet to the fire. I don't know about you, but I'm tired of tiptoeing around on scorched feet.

[Christie Downing]

Worth it? Hardly...I forgot who said it above that we are "treated like kindergardeners"...but that statement is true isn't it? I'll even take it one step further and say we are being treated like the teenager who is to never be trusted. It's taking a lot to have our trust earned back. Are some patient's suffering? Definetely! Everyone? Most certainly not.

Do I think the government has their most noble efforts at heart? No.

I don't think intimidation is the best way to envoke change...but it sure has given us a swift kick in our pants, hasn't it?

Has SOMETHING good come out of medicare regulations?...PERHAPS. Even if we've been backed into the wall, we've come out of it with some more knowlege.

However, just in case some of you MIGHT think I'm an idealist, this is what I'd really like to happen sometime: I'd like some CMS executive wind up in the hospital with a bad case of cellulitis from primary lymphedema and need IV ABX under the care of Medicare. They know they will need a course an IVs for 4 weeks. Then I want them to realize that they won't get coverage to have a home health nurse come once a day to run an IV (nor can they affort the $1000 or so a day the drug costs), nor will they pay for outpatient admisitration, BUT they can get sent to a nursing home for four weeks for the IV ABX. (I hope they are crunching the numbers at this point). When this person's infection begins to subside and they need lymphedema management, but no one at the nursing home does this treatment...only someone down the street at an outpatient clinic...I want them to realize they are missing and opportunity to get the treatment they need. This is because, of course, they are in a nursing home so they cannot be getting lymphedema management at an outpatient clinic. Then I want them to go back into the hospital when the cellulitis relapses and turns into open wound. When they FINALLY make it into outpatient therapy and realize they'll only get about 6 visits (is lymphedema management one of the "exempt" dx? I don't know, I'm in a hospital based setting) and realize that Medicare will pay the $1,000,000 their past 6 weeks of hospitalizations has cost, but will NOT pay for their custom fit compression garments that cost about $600 and have to be replaced every 4-6 months (and by now of course, the patient it broke). I hope THEN the executive will realize how arbitrary and illogical some of these regulations are. Paying for the aftermath but not the prevention? How silly.

Finally, I agree that we have the capability of becoming better without intimidation...but I think there are many in our profession who would simply aquiese the situation (ie, continuing their current practice without any thought on evidence based practice).

[Selena Horner]

No, Christie, I'm not missing or misunderstanding your point. I am full heartedly disagreeing with your stance. Not a single clinical research study has occurred because of the insensible regulations that I questioned. Those regulations that I believe are ridiculous do nothing except paint us into a corner - a corner that eliminates full professional judgement, a corner that substantially reduces our ability to make a profit (do you think any physical therapy business could survive on 100% Medicare patients?) and a corner that leaves us little control.

Just because there happens to be more and better clinical studies within the last 10 years does not mean that the insane regulations have driven researchers to produce research. The clinical research does not nicely compliment the regulations and it is ludicrous to imply cause and effect just because they seemed to occur concurrently.

[Christie Downing]

Are you saying that you've never reviewed how you were treating someone based on an HMO's refusal to allow a patient to have more than 6 visits? It is the same scenario in the sense to which I am referring. When this happens, and despite our best efforts to obtain more visits, don't you find youself compelled to deliver the most clincally sound care? When you've got a certain dollar amount to spend, don't you research and choose which treatments will give the most effective care? These mere instances drive me to carefully evaluate the literature (and propose certain studies).

While I certainly cannot prove the link between Medicare research and validity studies, you cannot prove that certain studies were NOT motivated by medicare pressures. I know a potential loss in profit would motivate me to validate my work!

My statement about you misundestanding me has to do with the fact that you posted "The reason you aren't able to come up with anything for my questions is because there is no research that supports those regulations. The regulations were not implemented based on any research nor has any research supported the benefit of those ridiculous regulations." This was certainly not my message. My message was simply that when given lemons, we've made lemonade (again going back to PPS, we've been able to identify that acute rehab is not always necessary after joint replacement, furthermore, we've been able to identify who is more approrpiate for SUBacute rehab and that a certain population does just fine with home health care)...whether our lemons come from Medicare, HMO's, or whatever.

I certainly do not like the regulations anymore than you, and I agree that they have been underminding our professional judement and they reduce our profits, etc.

...but I continue to think my message is being twisted. If you reread my posts, I think you'll see we meet eye to eye on certain points.

[Sean Weatherston]

So let me get this straight- if a chiropractor, massage therapist, kinesiotherapist, biomechanist, athletic trainer, personal trainer, exercise physiologist, or physician performs "PT" or has an aide perform "PT" we get up in arms. But it's ok for an aide to perform "PT" when it's a PT telling them what to do? Why do you think personal trainers, exercise physiologists, etc. encroach on our practice? My opinion is that we've taught them how to do it by giving them a false sense of security in our own clinics by being aides, techs, etc. Did you ever think that maybe the reason our reimbursement is pushed so low because the third party payors know that most of the care received in the clinic is provided by an aide getting paid $10 an hour? What does it say about our profession pushing for doctorates, begging for more reimbursement and the like when most of the care is provided by someone who has a high school degree and some on the job training in how to count to 30?

I guess I am an idealist, but certainly not an insulated one. I am a private practice owner who sees all patients one-on-one, without the use of aides, and business is good. Granted, my margins are much tighter than most other clinics, but I am making plenty of money and have happy employees and patients at the end of the day. I am also lucky to be in an area where we don't have insurance companies trying to give us $27 a visit so I do understand the demands that would place on an owner. Here's an idea...refuse the contract! I have no problem walking away from a company offering me less that what I need to keep the doors open. Call it idealism, call it a niche, call it whatever you want. I truly believe this is the best way to provide care.

[Larry Benz]

Sean:

thanks for responding. The central issue is not techs/aids, it is whether or not a PT should be able to use their judgment to delegate and direct care.

The initial examples you cite are irrelevant since they may depending on the situation be fraudulent.

You have decided that in your judgment, one on one is the best care and that is your prerogative as a licensed PT and in full accordance with your state practice act. The trouble is when people who believe similarly try and reduce the power of PT's who likewise are acting within their scope of practice which most if not all practice acts allow. Medicare thru superimposed rules as well as a few other payors are trying to put measures in place that simply don't comply with the practice act. Delegation and direction have been debated for years and there are various checks and balances (as well as position statements within our national association) that attempt to suggest where the fine line of those occur. My problem is not with your belief but with activist idealist PT's who are attempting to nationalize policy with payors to make medicare rules standard and who further more want to align every state's practice act to the same standard. This defeats the whole notion of an autonomous practitioner and moves us a major step backward.

I agree with you on the $27 per visit and would hope that most would as well.

[Ken Mailly, PT]

Larry, et al;

Allow me to submit the following questions:

If a State practice act or regulations were amended to allow anyone to provide Physical Therapy, without the need of any formal education or training, would we be OK with that?

Do we object to regulation in general, or just the regulations we don't like?

Most importantly: is this really an all-or-none proposition, and are there only two sides to this issue?

If so, it is the first time in human history that such a point has been reached, IMHO.

In the final analysis; I'm neither, because I'm both.

[Larry Benz]

Ken:
I am not in favor of changing practice acts at all unless they do not have direct access. I am very much against the PT idealist activists that are trying to change practice acts-specifically the right of a PT to delegate and direct as they deem necessary.

I often use the personal training analogy to see the complete difference between a completely unregulated business and ours which is over regulated. The last thing we need is for payors and practice acts to adapt medicare guidelines as the standard.

[Ken Mailly, PT]

"I am not in favor of changing practice acts at all unless they do not have direct access."

So if the practice act allows direct access to PT, but does not restrict who can render the PT, you would support such an act, even if the rendering individual is not a PT?

[Larry Benz]

Ken, not sure I follow you. Most state practice acts that I am aware of have very reasonable delegation and supervision requirements. The PT carries the responsibility and the liability for adhering to their practice act, standards of practice, documentation guidelines, position statements by APTA,etc.
I am against the PT activists that are trying to take power away from PT's.

[Ken Mailly, PT]

Let me put it this way: PTs are not the only ones who can successfully amend a practice act, and it is entrirely possible for State law or regulations to allow non-PTs to practice and be reimbursed for PT. In fact, this very situation exists in Maryland, for example.

It is folly to think that the cure for our ills is elminating regulation, if that is what some people are suggesting. Doing so is, at best, a double-edged sword; and at worst, self-defeating. I say this as a Practical Idealist.

[John Ware]

Ken,
I've practiced in six states, and in none of them was the practice act as restrictive in terms of supervision as Medicare. If it's true that we are governed under a federal system, where rights not enumerated by the Constitution are left to to the states, why is it that our health care system of regulation is effectively dictated by the federal government? Show me anywhere in the US Constitution or Bill of Rights where health care provision or regulation is mentioned. The only place that comes close is in the Preamble where the most over-interpreted words of all time exist: "promote the general Welfare."

How is it that an agency of the national government telling a PT that he must provide "direct, on site supervision" of a PTA performing an US in an outpatient clinic, but not in a patient's home, in any way promotes the general welfare? That directive is not only ludicrous, it's contradictory.

With regards to your double-edged sword: bring it on-the lazy, inefficient and ineffective PT's who don't keep up with best practice will be the one's to get cut loose. That's the least of my worries.

[John Ware]

Ken,
Here's the latest update from those all-knowing, all-seeing folks at CMS. Today I got a memo from our billing manager that we can no longer bill for manual therapy and mechanical traction in the same visit on the same body part. No, we're not even talking about Medicare patients, but Physician's Health Plan (PHP) figures, if the US Government can get away with these senseless CCI edits, why can't they?

I realize we're not talking about CCI edits, but the fact that CMS gets away with this blatantly irrational scheme that effectively intervenes in the clinical decision making of a health professional is obscene.

It's beyond me how any PT working today in the real world can begin to defend or justify the value of current Medicare regulations.

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[Leanne Burns]

Private practitioners must infiltrate policy making bodies...unfortunately, we are all too busy trying to keep our heads above water and working in the trenches to do so.

My biggest "pet peeve" is that everyone focuses on "woe is me" and how declining payments are hurting us (I agree)...but CMS/HHS doesn't care about that! We keep harping and they keep cutting. How about showing them how much money we are SAVING them? (Through reducing surgeries, fracture prevention, first line back pain management, etc.)

We need to throw "the dog" a bone--and make it a meaty one!

[Jeff Hathaway]

I have clinics in a State where the use of any provider other than a PT or PTA is against the law. I also have clinics in a State that allows the use of techs. If I am totally honest I beleive that what bothers me most is that what techs or PTA's do is not brain surgery and I can teach almost anyone in 2-3 months of working with me how to do the job well. And I am held hostage by a shortage of PTA's? Why should i be held hostage by a practice act and have to pay for the same level of work $40-50K in one State and $20-25k in another! The PT's use and oversight of that person determines the quality, not a 2 year degree.

I really appreciate EIM and Larry in this case for saying out loud what most of us have been thinking to ourselves or saying in private for years. The actions we observe from the idealists speak so loudly that i no longer care what they are saying. The problem is the idealist in our profession rarely have to live with the consequences. Seems like we should go to a system of referandum votes by the members in any State or Nationally. At least we would have "the will of the time crunched PT" heard.

[PaulS]

I just spent a few minutes looking at some of the sample notes at the Defensible Documentation site on apta.org. Wonder who actually writes a 2 page long note for each follow up visit and a 6 or 7 page evaluation for a total knee replacement?

This seems to follow the topic here...

[Michael Harris PTA]

Larry,
I understand rational for thinking and your right. I agree PTA’s do need increase education to at least a 3 year program. As to your other comments, I disagree with your ideal of basically wanting to do away with the PTA as a liability or due to your thought on insurance. You have always tried to stay one step ahead of the insurance company as for reimbursement (mainly Medicare). I feel the main fact hear is that PTAs need to increase the education level to stay in a ratio that fits more closely to that of the PT. Though as someone had mentioned in the comments we are not brain surgeons as for what we add to a practice we are part of a team; such as a PA is to MD, or a Nurse.
What’s the difference in placing ground troops in Iraq if all we need really is the Fighter Jets to bomb everything so that it makes things easier? A Pilot has much greater skill, education and training than a single GI.
This has to do with numbers. We have different skill levels. However, the key is to keep up with the changes that are taking place.
As for Medicare or any other insurance they know abuse is a problem. I have found that some physical therapist, tend to extend goals beyond a patients reach, unrealistic for an individual.
I understand codes, what’s covered by individual insurance, I am aware of the cost of supplies, lease, office, billing procedures, DME coverage etc.
In one year I will have a BS in physical education field.

So Larry, what do we do to change the education for PTAs to increase education? Is this the main problem or is the idea to rid the PT profession of the PTA?

[sean]

Sean,
isn't 90% of the work done in doctors' offices by the same $10 an hour employees? Why do you think MA certificate programs are so popular?
Michael Harris, PTA's are not akin to PA's as PA's can practice virtually independently and provide evaluation/treatment planning. What I will say on this issue is that I really liked the idea of the former PTA to PT transitional programs that existed in the 90s. I am not sure of all the details, but they basically required year(s) of experience and then traditional coursework.
Ken Mailly,
You make some good points. However, I think you are overplaying your argument for/against regulation. However to discuss it in a blog would require waaaaaaaaaay too much typing.

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[Herb Silver]

As an "idealist" "insulated" owner of a private practice in a free standing clinic that has absolutely no associations with physicians and actually does almost no marketing--the only way I stay in business is that the service and treatment is so much better than what passes as physical therapy in other clinics that see multiple patients at the same time and use unlicensed personnel. Go ahead and harp on this all you want. When it comes down to providing care in a fee for performance environment, your business model that excels in the (regressive) fee-for-service model that we all seem to hate but successfully exploit will fail. If you continue to promote this model, we will be replaced with trainers, ATCs and kinesiologists. If you can't figure out how your skills differ from these other folks you will help to end the profession I enjoy practicing. At that time, I should have enough patients paying out of pocket that it will not matter to me professionally, but it will truly be a shame to those wishing to provide specialized care. Anyone wanting to debate me in public on the issue, I would readily accept.

[Julia Overstreet]

As a physician and a lymphedema patient. I just want to thank all of you for fighting this battle. You give me hope that all lymphedema patients will one day have access to care.

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