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Rage and Furor

that’s the only way I know to describe the sentiments of PT’s and the entire medical community over the inability of the Senate to pass HR 6331 which would have avoided a 10.6% cut in fees for medical providers and for us PT’s it would have extended the exceptions process.

My observations:

-the method to avoid the fee reduction was actually well founded (and reported many times at this blog including here and here and here) in that it sought to reduce the premium paid to private insurers that is above the cost that CMS could administer the plan itself.  I believe Mr. Obvious would site that politics played a role in the Senate not passing this

-A system where the cap is in place for everybody but hospitals is just illogical as CMS’ data clearly shows that hospitals are losing significant market share in patients obtaining care in that outpatient setting. I challenge anybody in the profession to explain with any logic the reason that hospitals are exempt

-I am steadfastly against a cap for most of the traditional reasons that have been cited but also because it is unprecedented in the CMS system.  Can you imagine a cap on imaging or seeing a family physician?  Does CMS easily forget that PT is less than 2% of their budget?

-I am equally against the exception process. All it does is increase our cost (essentially decreasing reimbursement) thru an additional administration burden that while occurring infrequently casts a disruptive process to a PT clinic

I predict that somehow the 10% reduction will get dealt with because it is an election year.  I am not as confident on anything related to PT.

I highly commend APTA and groups like PTPN for their yeoman’s work in organizing the troops of PT’s to lobby for the passage of the legislation in both the Senate and the House.  What I cannot understand is why can’t we get the same sense of mobilization for the rules that CMS has put in place that profoundly impacts PT at much greater rates and financial implications than the Cap?  Why can’t we get PT’s on Capital Hill with the same rage to fight for the following:

-complete elimination of the stupid plan of care requirement that has gone from 30 days to 90 days without any clear implementation (now I know how Seniors felt about figuring out their new Medicare Part D drug benefit).

-elimination of all of the rules that are directly against practice acts and eliminate judgment by PT’s who are now in supposedly a “doctoring” profession including 8 minute rule, explicit providers of PT and PTA’s only, supervision requirements of PTA’s and students that are grossly inconsistent, the whole “group” therapy mess, and elimination of the requirement of physician referral

Why do we simply sit back and assume the position referred to in the 1978 film Animal House along with its phrase “thank you sir may I have another” ?

Perhaps the time has finally come when the PT’s around the US can lobby for all of these things together rather than a piecemeal approach that overemphasizes a cap that occurs at much less frequently than the practice superimposed rules that severely marginalize our profession and undermine the professional medical judgment of a PT.

Thoughts?

larry@physicaltherapist.com

Terminal Degree? Doctor? Felon?

The AMA may be going bananas about the evolving world of healthcare and the evolving role of physicians.  Larry implored the AMA to forget their proposed movement to restrict the use of the terms "doctor," "resident," and "residency" to physicians and just go golfing instead.  Well, it seems that some must have hit the links, but not all.  Ultimately, the AMA chose to abandon that resolution and instead adopted a resolution which calls for legislation that requires health care professionals to "clearly and accurately identify to patients their qualifications and degree(s)" and make it a felony to "misrepresent one's self as a physician."

Insiders at the meeting feel this resolution could be used by some state chapters to move through legislative efforts to limit the use of those terms, perhaps making the "misrepresentation" a felony!  Illinois, watch out, as it was that state's delegation that introduced the initial resolution. 

I found this letter from the American Society of Health-System Pharmacists (pdf) commenting on the proposed resolution, which apparently played some role in the movement away from the restriction of the term "doctor".

This article contains a list of other actions taken by the AMA at their recent meeting which serve to protect a physicians right to control your healthcare.  Remember when the AMA acted to make it a felony for any physician to voluntarily associate with an osteopath?  You can read about the AMA history with Osteopathy at Wikipedia. 

When considered historically, how can we trust all these actions that serve to protect physicians' scope of practice?  Is it possible there are cheaper, more efficient ways to obtain good health?

ERIC

Leveling the Playing Field

On June 23, 2008 the New Jersey General Assembly took the first step in restoring some sense and reason to the practice environment for Physical Therapists and healthcare consumers in the State of New Jersey by overwhelmingly passing Assembly Bill 2123 (A-2123).  This landmark piece of legislation seeks to establish standards of coverage and reimbursement that are commensurate with the standards of practice by which Physical Therapists in New Jersey are bound to abide.

A-2123 assures consumers that the coverage that they and their employers pay so handsome a price for will indeed provide services without arbitrary caps on payment for services rendered or visits for medically necessary services.  As we are all painfully aware, third party payment for Physical Therapy services has been in a downward death spiral.  A-2123 establishes a floor of reimbursement based on an already existing PIP fee schedule established by the State of New Jersey below which the insurers' liabilities may not fall.  It also provides for the elimination of capricious and arbitrary visit authorizations less than those proposed by the treating Physical Therapist's Plan of Care should authorization be sought.  This legislation also makes Direct Access an affordable option for consumers by eliminating all referral requirements for third party payment for Physical Therapy.  There are a host of other benefits of this legislation which are covered here.

When all else has failed there are other avenues that are available to combat the deterioration of the practice environment and the legislative arena is the one most apropos when all other avenues have failed to produce satisfactory outcomes. 

The Senate companion bill of A-2123 was introduced last week as well in the form of S-2072.  I for one am looking forward to the passage of this bill as well and the eventual enactment of this legislation by the stroke of the Governor's pen.

Summertime PT Fun Test-see you how you do

It is time for the first annual “are you smarter than a PT regulator?” test.  We will start out with a sample question and then get right into it.  Please do not look at the bottom for the answers and explanations until you have completed the test.  Be honest, post your scores and your thoughts.  If you are too scared to post them on the blog, please email me privately.  Academic programs-particularly interested in how your students performed.  Perhaps it might be better for them not to take this since it might scare them out of the profession!

I realize that PT’s are exam phobic. However, I thought this was the best way to illustrate the absurdities in our industry.  Sorry in advance for the length of this blog post.

Sample Question:

Which of the following are the only providers under medicare’s rules to have a physician signed plan of care:

A. Chiro’s

B. Optometrists

C.  Physical Therapists

D. Dentists

E. Proctologists

The answer is C of course.  Why don’t we fight against this? who knows. In fact the recent change from 30 days to 90 days has caused more confusion and questions than it has answers, particularly the physicians who are now asking questions about plans of care that last 10 weeks!!

 

Medicare Physical Therapy Economics:

1. Which of the following received the most payments in medicare for PT services:

A. Hospital

B. Skilled Nursing Facility

C. Physical Therapist Private Practice

D. Physicians

E. Outpatient Rehabilitation Facility

 

2. Hospitals have always been exempt from the medicare cap.  Between 2004 and 2006 which provider setting has seen a decrease in percentage of medicare beneficiaries seen in their setting:

A. Skilled Nursing Facility outpatient (medicare part B)

B. Hospital Outpatient

C. Physical Therapist Private Practice

D. Outpatient Rehab Facility

E. All but C.

 

 

3. Approximately 8.5% of the 43 million medicare patients annually access PT. What percentage of the 179 billion part B medicare budget goes to PT?

A. 2%

B. 4%

C. 6%

D. 8%

E. 10%

 

4. There were approximately 4% more PT’s seeing medicare patients in 2006 than in 2004. This resulted in the following:

A. about a 4% rise in physical therapy expenditures in 2006

B. a 10% rise in 2006 sending all kinds of “red flag” to medicare about PT usage

C. There was no change in expenditures between 2004 and 2006

D. There was more than a 5% decrease in PT expenditures between 2004 and 2006

E. None of the above are true

 

Medicare Regulations:

5. Which of the following are not allowed as billable time under medicare:

A. A ventilator dependent skilled nursing patient is in being treated by a student under supervision of a PT.

B.. A ventilator dependent skilled nursing patient is being treated by a therapist extender under supervision of a PT.

C. An ATC working as a therapist extender is counting the number of straight leg raises of a medicare patient.

D. A physical therapist assistant working solo in an outpatient rehab facility is performing manual therapy on a patient.

E. PTA working solo in a outpatient rehab facility is doing soft tissue massage

 

6. A PT is working with a medicare patient.  After examination and applying a clinical prediction rule, the PT decides to do a manipulation thrust technique on a patient which after looking at his clinic supplied (and CMS approved) stopwatch took 5 min.  Concurrently, a therapist extender is working with a non medicare patient counting the number of straight leg raises.  What is the correct billing?

A.  Wow, too difficult to tell-so I will take the safe route and bill it as “group” or not charge at all

B. A no charge on the thrust technique since it took less than 8 minutes.

C. Assuming the pre and post treatment times are added to the stop watch, it is a safe assumption that it took 8 minutes BUT the concurrent patient was being supervised by the PT so the thrust technique is “group” therapy.

D. Manual therapy thrust techniques are not allowed on medicare patients-at least not in my clinic.

E. This scenario is stupid. It is immoral, unethical, and impossible to manage more than one patient at a time and the fact that you have even used the words therapist "extender" is a disgrace to our profession-am done with this stupid quiz that I am failing.

7. Which of the following are part of a typical state practice act in PT:

A. Certification plan

B. 8 minute rule

C. Restriction on billing for work performed by students in an outpatient setting

D. Explicit definitions of PT and PTA as the only providers of service

E.  None of the above

8. Which of the following according to CMS are not allowed to make “clinical judgments”?

A. PT

B. PTA

C. ATC

D. Therapist Extenders

E. All but A

9. Which of the following payors most restrict the clinical judgment of a PT?

A. CMS

B. United because they pay the least.

C. Work Comp

D. Private payors in general

E. None of the above.

10. Many hospital PT’s are very concerned that effective July 1, PT extenders under direct supervision will not be allowed to work with medicare patients and have their “minutes count”.  Which National Organization has lobbied for the continued use of therapist extenders in the part A environment:

A. APTA

B. NASL

C. AARP

D. ASPCA

E. NAFTA

11. After Nuclear Power plants, which industry is the most regulated:

A. Health Care.

B. Construction.

C. Insurance

D. Financial services

E. Pharma

12. Which of the following will most help Tiger Wood’s with pre-op exercises?

A. Self-help DVD

B. An exercise sheet of knee exercises given by a physician with a popular anti-inflammatory as the sponsor of the exercise handout

C. a Nintendo Wii

D. A therapist extender under supervision of a PT after a clinical exam by the PT

 

13. A Senior PGA tour player who has medicare has just been referred to PT for knee pain.  Which of the following are not considered billable?

A. A therapist watches a self help DVD with a patient

B. A PTA reviews the exercise sheet given by a physician

C. PT plays Nintendo Wii bowling with a patient

D. an ATC (therapist extender) under supervision of a PT and after a clinical exam by the PT is working with the patient on straight leg raises

E. all of the above are billable under medicare

 

14. All of the following are supervision terms used by medicare except:

A. General Supervision

B. Direct Supervision

C. “line of site” supervision

D. “same room” supervision

E. All are terms used by CMS

 

15. Hospitals are exempt from medicare’s cap for outpatient PT.  This is because:

A. Hospitals are the preferred provider of CMS

B. Hospitals have shown that they are the most cost-effective providers of outpatient PT

C. Hospitals have always believed that all PT should be “one on one”

D. Hospitals have the lobbyists with the biggest bucks and biggest influence in Congress.

E. Nobody really knows-just another stupid rule by the government

 

16.  The medicare cap for PT is combined with speech and language pathologists while OT has its own cap.  The reason that it is combined is:

A.  Everybody knows speech therapists really want to be PT’s so they just went ahead and combined them

B.  Allows co-treatment of PT and Speech without regards to total dollars

C.  So few outpatients need speech that they figured “what the hell, let’s just combine them”

D. They knew they couldn’t combine PT’s with OT’s or there would have been a hell of a dogfight

E. Nobody really knows-just another stupid oversight by the government

 

 

ANSWERS:

1. C.  PTPP dominate the medicare outpatient physical therapy world with a 35% market share with hospitals having 21% and physicians 9%.  Although PTPP is by far the largest, it cannot be determined how much of PTPP is truly outpatient PT owned by PT versus outpatient PT that is owned by MD’s.  We do know that the biggest rise between 2004 and 2006 data was PTPP and it is presumed to be physician owned growth since that is when MD practices were allowed to start applying for their own PTPP numbers. In fact, physician data to CMS actually decreased during this same time due to the transition of MD practices billing “incident to PT” to PTPP.

2. E.  All  but PT in private practice have seen a decrease in the number of medicare beneficiaries in their setting.  Right wrong or indifferent, physical therapy private practice is where the medicare “action” is yet the ridiculous superimposed rules by CMS are making financial viability in a private practice challenging to say the least. I am sure there are several reasons why medicare patients don't go to hospital outpatient clinics for PT even when they have a financial incentive to do so.

3. A.  In fact, it is less than 2% at 3.05 Billion.

4. D.  Per CMS data PT expenditures went from 3.23 B to 3.05. They are trying to credit the medicare exemption process. Grade them an F for terrible analysis.  This is surprising since hospitals are exempt from the cap but then again, hospitals are losing substantial market share in outpatient PT.

5. C.  CMS allows students and therapist extenders on part A medicare but not part B. Don’t try and figure it out-logic won’t work.  I have no trouble with the therapist extender in these settings as  I fundamentally believe that PT’s can and should be in the position to make those determinations.  Unfortunately, the trend within our profession is to eliminate all therapist extender positions within an outpatient setting under the mistaken belief that the care is “unskilled” or that all PT requires “clinical judgment”.  Their stupid argument goes something like this: Why should an insurance company pay for services that are “unskilled”?  Is taking height, weight, and blood pressure skilled? (ok, sorry about a “quiz within a quiz”).  Does medicare pay for those services in conjunction with a physician’s exam?  The only factor that should matter to any payor is whether or not the PT is acting within their scope of practice.  Just because something is “skilled” is not the benchmark for payment as any profession has to have support services and a complete inability to pass the cost of the support services along so that a therapist can be more efficient destroys the utilitarian ability of a provider and the ability to be the most cost effective.  Don’t all professionals have support staff that assists in an overall delivery?  Lawyers use paralegals or clerical help that they bill for as do accountants and almost all other “real” professions.  On the one hand, we want to be the Vision 2020 Doctoring “profession”. On the other hand, we want to police ourselves out of an industry under the mistaken belief that we need to "clean" ourselves up or that it is immoral professionally to use support help.  Let’s fight for consistency in all settings which allows PT’s to use their judgment in accordance with their practice acts and keep in mind most practice acts have provisions for support “extenders” which calls for some level of competency and review of competencies. 

6. C but this question would not reach the threshold of psychometric properties since answers would be all over the place and it would have to be tossed out of the test.  The number of similar type questions are constantly being asked and debated in clinics and listserv’s throughout the US.  What a waste of time.  PT’s don’t go to school to figure out some counter-intuitive definition of group therapy.

7. E.  All of those are part of the medicare superimposed rules that are breaking the backs of PT’s.  We get so used to them that we often think they are part of our practice act.  Shame on us.  We need to fight for their elimination rather than passively sit back and have CMS keep adding them towards our extinction.  We also need to restrain the efforts by many in our profession who are actively promoting CMS as the standard and are pushing for all payors and practice models to adopt them as standard.

8.  E. Per CMS’ own language   PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.” Since we know therapist extenders can’t likewise make clinical judgments why don’t they let their work count since they are allowed in almost all state laws?“

9. A.  Most practice acts allow for the use of therapist extenders provided they have received training and an annual review of competencies.  By disallowing therapist extenders (outpatient only under CMS) they restrict the therapists decision making in delineating what it most cost-effective resource that should provide intervention.

10. B. The National Association for the Support of Long Term Care.  Why hasn’t APTA stepped up to plate on this?  Perhaps they are too worried about the politics of “taking sides” in an organization that is split on the use of extender issues.  My take is they have no guts.  A simple and defensible position ought to be “We believe that PT's are fully capable of acting within their scope of license within their state practice acts.  In regards to the use of extenders, provided their state practice acts allow for this, we defend a PT’s ability to make clinical judgments for the patient's best concern”.

11.A.  This one isn’t even close.  More federal and state regulations for health care than any other industry than nuclear power!  Think of HIPAA, ADA, OSHA, corporate compliance, etc. etc. As an aside, nuclear power plants have a problem called NIMBY (not in my backyard).  Perhaps CMS doesn’t want a PT clinic in your backyard either!

12. D.  Hope there is little debate on this one.  My assumption is that a room full of academics and practicing PT’s would come to the same conclusion.

13.D.  Crazy world we live in.

14. E.  Aren’t you glad you went to PT school to learn at least 4 different types of supervision!!

15.  E.  Lots of speculation, no real explanation.

16.E.  PT represents over 75% of all outpatient therapy spending.  It makes sense to combine its cap right?

Post your grades and your thoughts please.  Hopefully many of the question will irritate you and perhaps even convince you to come onboard a grass roots movement to “operation restore PT”.  We have let regulators “gone wild” on our profession and need to restore logic and reason to rules and regulations so that we can spend time providing the best in evidence-based care to our patients rather than worry about “line of sight” supervision and determination of “group” therapy.

larry@physicaltherapist.com

 

Those Pesky Self-Help DVD's Again

I've never been a fan of Advance for Physical Therapists & PT Assistants.  (I'm still not a fan.)

For some reason, this kindling made it to my door... and for some reason I opened it up.  The last page happened to have the opinions of 4 individuals on self-help DVD's for various common conditions.  We've discussed this before, I know.  I was just floored by the lack of the ability to truly respond to the question and the opinions presented. 

Let me paraphrase the responses to:  Do rehab clinicians feel these resources play a role in easing painful conditions?

PT #1:  They are a treatment option.  Therapists must be aware of the vast amount of information and offer professional guidance.  My thoughts... Hello... if the potential patient is purchasing a DVD, do you really think you're going to have the opportunity to offer any professional guidance? 

PT #2:  Using the latest technology is just one avenue to give people the freedom to live a pain-free life.  My thoughts... Oh, oh... so as our research points to defining subgroups of patients and their responses to particular interventions, will a person really be able to identify the appropriate subgroup and match the appropriate exercises/tasks?  Hmmm, and is a pain-free life realistic?

PT#3:  Selling DVDs is a source of cash revenue and can promote physical therapist expertise. My thoughts... ummm, well, does the DVD ease painful conditions?  Will the DVD meet the expectations?

MD #1:  Why, oh why, did our fellow colleagues not sound as fabulous as his response?  Ryan Reeves, MD  "Without appropriate supervision and guidance, patients miss out on the integration of their clinical signs, symptoms, exam findings and test results."  I loved his final ending, "Without guidance, the most you should expect is mediocre outcome."  The only negative with Ryan is it appears he's practicing in a referral for profit situation.

Let's pretend the DVD's do have great information and are created by physical therapists.  If the consumer has the expectation that the self-help DVD will resolve the current complaint because the DVD was created by a physical therapist expert... but then the DVD wasn't beneficial, didn't help or made things worse, how exactly will we be viewed? 

It might be nice to see a clinical trial where patients are provided with a DVD and allowed to make all the decisions (with pre and post outcome data) and compare their self-help outcomes to physical therapist directed services.

Selena Horner 

How about "Cure from CMS" ?

and any other payors that superimpose rules that are above our Practice Acts?

The AMA released a campaign today called Cure for Claims complete with a report card. 

Per AMA Board Member William Dolan, “The goal…is to hold health insurance companies accountable for making claims processing more cost-effective and transparent….eliminating the inefficiencies of the billing and collection process would produce significant savings that could be better used to enhance patient care and help reduce overall health care costs…”

Amen!

I love their report card and the metrics that it measured and believe they are consistent in the PT world.  The adherence to contracted rate ranges from 61% (United)to 98% (Medicare).

Thoughts?

larry@physicaltherapist.com

 

Post Mortem-APTA Meeting

Some observations after the meeting in San Antonio.  I appreciate the posts on the Rothstein Debate, Oxford Debate,  and thoughts from the day after.

-although the attendance was around a paltry 2000, I found the attendees highly engaged and very active at educational events-except of course the Sat morning “hangover” sessions of which of course our group’s direct employer contracting session took place. 

-why do we even have 2 national meetings per year?  Most can get it done in one and CSM programming is far superior.  I distinctly remember discussion of going to one meeting-has that been lost somewhere? 

-highlight of the meeting was the McMillan Lecture by Dr. Tony Delitto.  Both insightful and practical, let’s hope at least the researchers and PT programs are encouraged to make changes based on Tony’s suggestions

-the real winners in this year’s Rothstein debate are hopefully future students who will be be licensed eligible after two years with an “hinged” terminal internship/residency for the final year in obtaining their DPT.  This will result in significantly less cost born by the student (and in large part shared by the employer doing the internship), better “real world” training, and complete solving of the CMS rule that does not allow students to touch patients.  Our students and profession deserve such a change-we just now need the 200+ PT programs to get motivated-in their hearts they know a change is needed

-The most important issue in our profession continues to come to the forefront and it is perhaps the subject of next year’s debate, a pending house motion, and substantial endorsement by private practice PT’s and Practicing Practicals: we got to put an end to this madness of promoting superimposed rules to our practice acts by those in our professions (who most notably are hospital PT’s who get 2–3x the reimbursement rate that private practice receives).  It is one thing for a payor to have a “reimbursement policy” that says they won’t pay for a hot pack, it is quite another for them to have “practice” policy that negates our practice acts, position statements by our national association, etc.  How can we idly sit by and see our profession regulated to its death?  Why do we have so many that don’t recognize that these superimposed rules marginalize and replace our practice acts?  Why are so many influential PT’s in our profession in favor of this?  Where did the idea come in that a PT cannot possibly manage more than one patient at a time, every aspect of a patient’s care has to be done by a PT or PTA, and that the judgment of a PT in managing a patient should be replaced by a payor rule rather than governed by their practice act?

Thoughts?

larry@physicaltherapist.com

The Oxford Debate

Should physical therapists remove the use and billing of selected physical agents from their practice (ultrasound)?

Were some of you present at this event?  There were two teams:  One team supported maintaining the use, billing and teaching of ultrasound as an aspect of the services we provide; obviously, the other team disagreed.  Although the brochure suggested laser to be debated, the focus was mainly on ultrasound.

Of course, prior to the beginning of this debate, the room was obnoxiously loud with those clappers.  Ben Hando might have tolerated the environment... I doubt he would have tolerated the actual debate because somehow I ended up seated next to the same colleague that got me into trouble the other day.  Everyone was concurrently speaking among each other and there was a lot of racket and switching sides of the room.  Yes, it was entertaining and yes, it was lighthearted.  I certainly hope there wasn't a goal for anything to be accomplished with this event though.

If we really want to be considered neuromusculoskeletal experts, I really do believe we need to sit back and reflect.  The members of the teams, in my opinion, were more familiar with the world of academics (and they have accomplished good things for our profession and our patients) - and my mentioning of this isn't to create a divide but to instead put some reality into the debate.  None of them mentioned the financial impact of our clinical decisions.  There was some data that could have been used to indicate reality which wasn't brought into the debate by either team.  The only data that I have at my disposal is from CMS and it should be considered and reflected upon.  As Tony Delitto quoted from Forrest Gump... stupid is as stupid does... THIS is what CMS knows we are doing:

The results for outpatient therapy services for calendar year 2006:

The outpatient therapy expenditures for physical therapy services:  $3,053,523,057

For the fabulous CPT code 97035 (ultrasound) for physical therapy services, CMS paid out a total of $74,437,656 and the total allowed for claims was $94,080,355.  The difference between what CMS paid and the total allowed ($19,642,699) is what Medicare beneficiaries paid for ultrasound.  When I look at that amount of money and I consider the research, it is unbelievable what we did.  Did Medicare beneficiaries get bang for their buck?

To then translate that into how many ultrasounds... For calendar year 2006, there were a total of 128,265,693 line items submitted to CMS for payment.  Of those line items, 7,465,223 were for ultrasound services.  (Assuming that each ultrasound was 1 unit, that's a lot of magic wand moving.)  This amounts to 5.82% of claim lines.

Maybe those figures seem reasonable, but let's take a look at the settings in which ultrasound was utilized (from highest use to lowest):  11% by physicians in "incident to" settings, 9.41% by NPP, 8.3% in PTPP, 7% in CORF, 6.3% in ORF, 6% in hospital setting, 3% in HHA, and 1.02% in SNF.  For definition of acronyms, The CMS document.  This data might substantiate a stance that physical therapists are utilizing ultrasound appropriately, but in all honesty, we don't know if a physical therapist provided the ultrasound or not for the top 2 highest percentage use due to data collection procedures.

Finally, what main diagnoses were treated?  724.2 (back pain) 9%, 781.2 (abnormality of gait) 5.3%, 719.41 (shoulder joint pain) 4%, 719.46 (knee joint pain) 3.8%, 723.1 (neck pain) 3.6%, 719.7 (difficulty walking) 2.8%.  If you happen to look at the document and wanted to know the rest of the top 20 diagnoses, you can easily find them here at Wiki.

I have no idea what occurs with commercial insurances, worker compensation claims or auto accident claims.  It makes me wonder though when I see the above data.

So, even though the debate was obnoxious, "entertaining" and lighthearted, in my opinion, we really do need to sit back and reflect on our clinical practice patterns and the financial impact of our decisions.  In all honesty, I couldn't really find the "fun" in that debate because reality is everything we do has a financial impact and I would truly hope that we would be trying our best to be both cost-effective AND outcome oriented.

Selena Horner

The 2008 Rothstein Debate

For those of you unable to attend, Michael Emery and Larry Benz debated whether the current clinical model adequately prepares students for practice.

One area in which students won't be adequately prepared for clinical practice is in the area of adequately treating older adults due to CMS regulations.  Both Michael and Larry agree on this issue.  Students are only able to observe... maybe palpate but only in the direct presence of the clinical instructor.  The current situation is a 3-way no-win situation for 1) the student, 2) the facility (due to students unable to bill for services which means there will be reduced productivity for the facility for any clinical instructor that has a student due to the need to take twice as long with patient visits so students can gain a less than adequate experience) and 3) ultimately the patient.  In my opinion, it is highly unlikely that students will be able to efficiently treat the older adults because they haven't really experienced the whole aspect of taking the lead and critically thinking on their feet.  Watching isn't the same as doing. This though is a regulatory issue that probably won't change any time soon.

I heard two sides of the situation.  Both actually seemed to agree that what is currently happening isn't adequate.  Larry believes the current model is broken.  Michael though doesn't necessarily believe the current model is broken, but that the current model hasn't been executed optimally. 

Keeping in mind that it is highly unlikely that federal regulations will change soon, Larry seemed to indicate that a solution that would reduce student costs and allow students to acquire the fullest clinical experience would be to gain the initial knowledge and skills for 2 years within the educational system, then become licensed and then finish with a residency program.  That could be one potential solution, but whenever strategies are implemented the risks and benefits should be analyzed.  The biggest risk to attempt to eliminate with this strategy would be the risk that once a graduating student acquired a license, the physical therapist would have to continue with a residency program.  I'm sure that there could be some kind of contractual agreement and potentially some sort of financial commitment or large financial deposit on the part of students at the initiation of becoming accepted into a graduate physical therapy program that might reduce the biggest risk in Larry's suggestion. 

Michael though seemed to indicate that the current model would be adequate if the model was executed better.  The current model does not have strong relationships between the academic program and the clinics.  The current model does have clinics accepting students from multiple programs.  Because clinics are experiencing a shortage of physical therapists, the "relationship" with an academic program might enhance the opportunity to reduce staff shortage situations.  At the same time though, some clinics are no longer accepting students because of the federal regulations which might also be potentially reducing the clinical sites available for students.  Michael provided data that seemed to indicate that a high number of students do become licensed and pass the exam on the first attempt; students seem to acquire positions generally prior to graduation and prior to being licensed.  If Michael's data is correct, then that would indicate that as a whole, there might not be a problem to the extent that that the system is broken.

My day after thoughts.... It was interesting to hear another therapist state that he's had concerns for the last 50 years on the level of clinical education.  (Obviously, there has been an unresolved problem for way too many years.)  After hearing that therapist speak and putting together both Larry's thoughts and Michael's thoughts, the problem really seems to be an accountability issue.  No one has accountability.  The programs aren't being accountable to the students because I'm sure they fear the risk of losing clinical sites for students if the model was executed properly.  The affiliations/clinics aren't being held accountable for the clinical competency of their own staff or held accountable for their own outcomes to ensure the most optimal experience will occur for students.  To be held accountable to this level would take time and money.  Maybe overall clinical competency and outcomes aren't a priority within clinics?  The students aren't being held accountable.  Students resort to learning from clinical instructors that as a whole are not necessarily practicing evidence-based practice and fear receiving poor competency evaluations from their instructors if the students chose to challenge the instructors.  Accountability still won't solve the federal regulation issue though.

I will publicly apologize to Ben Hando.  I'm sorry you had to shush me... I'm just as bad on a golf course.  It really was important for me to better understand residency programs in that period of time that your colleague was whispering a response to me.  If I were better at texting, I probably should have texted to him. 

Selena Horner

Thoughts from the Day After

For those of you unable to attend opening ceremonies....

The initial 20 minutes or so are typically spent on thanking and recognizing various individuals - Board members, APTA staff, and fellows.  (This occurred this year as usual.)

John Barnes, CEO of APTA spoke highly of Scott Ward and Scott's commitment to this profession.

Scott Ward spoke a second time and brought up a slice of CRT/Tanaka survey results.  News to me, but apparently a high percentage of the public do know what physical therapist do!  I can't remember the percentage, but it was somewhere like 80-90% of interviewed subjects.  Granted, no details on where these subjects resided, how close to physical therapy programs these individuals resided, the percentage of individuals who had received physical therapy services in the past...  This is somewhat concerning to me... Will there really be a focused effort to target consumers about us?  (I haven't had time to review the Strategy update yet.)  Of course, Scott in an indirect manner made the suggestion that we need to be proud of what we do and tell everyone what we do.

Lee Woodruff provided proof of someone who experienced the the compassion of physical therapists.  Her husband, Bob, was severely injured in Iraq by a roadside bomb.  She discussed the wide effects of a traumatic brain injury.  She highlighted the compassion, energy and motivational chacteristics of the physical therapists who treated her husband.  She and her husband, because of his experience, were inspired to do two things... write a book AND created the Bob Woodruff Family Fund for Traumatic Brain Injury for wounded servicemen and their families. 

For me, the biggest take home message from Woodruff was.... our military medical system rocks!  (I'm sorry that for me, I wasn't as impressed with the physical therapy aspect, but this is just my perspective.)  Her story of the efficiency, effectiveness and organizational preparedness emulates exactly what I have heard from a close friend who had a brother severely injured in Iraq.  What Christopher Blaxton experienced with the military medical system was the same outstanding care and responsiveness as the Woodruff's!  Today might be the last day for another conference occurring concurrently - the Army happens to be having a medical conference in the same convention center.  I know I'll take some time to personally thank their efforts.

Selena Horner