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Physical Therapy Law and Order

or maybe it should be PT CSI?

In either show, it would be a well played drama In what is most likely the largest fraud case involving 6 physical therapy clinics in Houston, Tex. 

We have:

70–count indictments

Medicare and Medicaid patients intentionally misdiagnosed (why is this not a crime for spine surgeons?) and billed for services that were never performed from 1996–2000

One defendant ordered to pay 5.7 Million in restitution

Multiple appeals with one including calculation of a 78 month sentence (math not a strong point amongst these crooks) and another involving conspiracy! 

A physician giving up his medical license, others still serving time

Is there a PT analog to all of the big time lawyers turned novelists?

While there is often a knee jerk reaction to the criminal cases of this type to want to further regulate PT, let’s remember that these cases all have malicious intention and are clearly crooked.  Some of these cases involve PT’s and others do not.  Let’s not penalize the overwhelming majority of PT’s that are trying to comply with the myriad rules and regulations because of the few.

Let’s do though try and get a few of these cases on one of the TV shows.

larry@physicaltherapist.com

 

Consumers with Knee Pain Searching for Answers

A week ago I was intrigued with a particular presentation that I researched to respond to Tim Richardson on episode of care/condition specific potential payment systems.

I found a 2008 presentation by Lanny L. Johnson, MD.  (Lanny Johnson, MD is probably well known in the circle of orthopaedic surgeons for his work in arthroscopy.)  Three slides really had me thinking and wondering about what motivates someone.

Within this presentation, it was news to me that surgeons lack surgical candidates.  There are authors here (obviously not me) that know the financial surgical costs and incidence of surgery occurring today.  To be fair, and to take into account the work of Johnson, the focus would need to be the knee.  It would be interesting to know the incidence of arthroscopic surgery on the knee combined with information as to whether the surgical candidates are appropriate candidates (in light of recent research suggesting arthroscopic surgery is not effective for moderate to severe osteoarthritis of the knee).

The abstract of this article on the ability to diagnose an anterior cruciate ligament tear or a meniscal tear via medical history alone appeared interesting.  I am excited about the prospect of using data to assist in diagnosing along with the capability to accurately diagnose because this avenue of thought can reduce costs by eliminating costly diagnostic testing.

It appeared to me that Johnson had a vested interest in reaching out to consumers to assist them when a knee problem occurred.  Introducing... Free Knee.  So, okay, I took some liberties and became a fake patient.  Why not?  I mean, I treat enough people with knee pain during the day that I could pretend to be someone and respond to a survey accordingly.  How about patellofemoral pain as a problem?  I decided that I'd pretend I had that issue.  If this works, here is my "data" on my condition:  data.  Honestly, the system did a great job asking questions overall.  I had issues with the "pain with physical therapy" area and the survey could be changed to be less "medical terminologied" but other than that it was reasonable, thorough and captured what physical therapists all capture in our subjective portion. 

So, I'm gullible.  I'll admit it, I am.  I was excited to see what Free Knee would tell me about my knee pain.  I went from being impressed to being sorely disappointed in less than 30 seconds when my personalized report appeared.  Don't ask me why I thought the report might have been different.  I believe people are inherently good, not selfish and try to serve others.  Well, the finding...  it is probable (89% probability) that you have a surgically treatable condition in your involved knee.  Imagine that?  Since when has patellofemoral knee pain had that high of a probability for needing surgical intervention??  Apparently, the motivation was more self-serving for the orthopaedic surgeons and the "news" that they needed more surgical candidates.  Obviously, the goal isn't focused on the appropriate patient at the right time.

Trust... how will consumers learn to trust anyone?  Free Knee really did create the impression of thorough combined with an ambiance that it just couldn't be wrong with it's final determination of what would help me get rid of my knee pain.

The internet is great... but buyer beware.  As consumers use the internet as a tool to help themselves, how can we position ourselves to not be self-serving, but really serve the needs of consumers?  And, how do we approach such situations if a patient were to bring in a computer generated report on their condition?

~Selena 

A thing of the past?

The NY Times today had a very interesting piece on Peter R. Orszag the Chief of the Office of Management and Budget.  Notwithstanding the fact that he might just have more energy than John Childs, there were some key insights into the perspective of his office on health care.  It indeed is the big gorilla that will need to be tackled and I facilate between hope and despair that true and effective change might actually occur.  After reading this at least I am a little more hopeful. Orzag reportedly wants to do no less than change the way medicine is practiced, eliminating unnecessary tests and unproven treatments in favor of what he calls a higher-value approach that he says will actually improve health.  Sounds like a broken record EIM blog post. Others might be questioning whether we should pay for ineffective 50K fusion surgeries, perhaps we should try a a couple hundred dollars of PT first.  

 

Baskets for Back Pain

In discussion with some colleagues in response to this recent post, I became aware of some "innovative" solutions that our fellow Minnesotans are apparently working on when it comes to improving health care for the most expensive conditions. According to the website, they are setting up "baskets of care" for the following conditions:

1) Asthma (children) - Management of asthma as a chronic disease

2) Diabetes - Without co-morbidities, does include hypertension and hyperlipidemia

3) Low Back Pain - Management of acute episode of low back pain

4) Obstetric Care - Consider prenatal, uncomplicated vaginal delivery, cesarean section delivery

5) Preventive Care (adults)

6) Preventive Care (children) - Well child care, preventive care, normal newborn care

7) Total Knee Replacement - Inclusive management from preoperative phase through rehabilitation phase

Little detail is provided on how they derived the list, but I suspect it's based on some combination of high volume/high expense (ie, low back pain) and opportunities to prevent some of it (ie, the focus on preventive care). The baskets apparently include "collections of health care services designed to treat particular health conditions or episodes of care" with a case rate form of reimbursement in which the provider is paid a flat fee, thus assuming some element of risk for the outcome. The approach of course is being pitched as a "major reform in the way we pay for health care" in Minnesota.

The concept of case rated reimbursement actually has some merit, but this is only the case assuming a level playing field in which all health providers share in the potential risk and reward. I am purely speculating in this instance, but if history of previous health care reform efforts is a guide, I am willing to bet that these baskets don't include the very interventions that got us into this mess in the first place (health care meltdown a la economic meltdown coming to a country near you...), primarily drugs, imaging, and procedures (ie, injections and surgery primarily). In other words, the playing field is anything but level, so any examination of the extent to which reform might work has to be subjected to the sniff test.

What do you suspect the likelihood is that physicians have been able to carve out their own special basket for things like drugs, imaging, and procedures such that they continue to be paid on a fee for service basis while we "plankton providers" (yet the only ones offering meaningful hope for reform) get case rated? I am willing to bet big. If true, highly effective care gets subjected to case rates (which again can be a very reasonable solution so long as everyone plays by the same rules), while largely ineffective procedures will continue to get handsomely and disproportionately rewarded, which only continues to make the problem worse.

Perhaps someone more familiar with the process in Minnesota can confirm or disconfirm whether a rat really exists in this or if perhaps there is actually real reform under way. I highly doubt real reform because you don't see the Golden Rule of health care policy in the U.S. get violated very often...policy making has nothing to do with what's best for the patient or our country as a whole but rather exists to serve special interests. So, while the Declaration of Independence might stipulate that all men are created equal, some in health care have bigger baskets than others and that's just the way it is. What say you?

John

EIM's Orthopedic Manual Physical Therapy Fellowship Awarded Status as an APTA Credentialed Program!

EIM's Orthopedic Manual Physical Therapy Fellowship Awarded Status as an APTA Credentialed Program! Evidence in Motion’s Orthopedic Manual Physical Therapy Fellowship Program is now credentialed by the American Physical Therapy Association as a post-professional clinical fellowship program. We are very excited to share this new, and we are thankful for the contributions made by so many talented, skilled, and hard-working professionals who helped to make this happen.

This is another important step for EIM in our work and mission to elevate the physical therapy profession and the role of physical therapists in health care delivery. In our residency and fellowship training programs, we seek to partner with and equip individual practitioners and physical therapy practices with premiere resources and training necessary for becoming leaders in evidence-based practice while creating and promoting a culture of evidence-based practice within the physical therapy profession. Our fellowship program, in particular, is structured not only to create highly skilled evidence based manual physical therapists, but also to mold and develop our fellows into leaders in our profession.

At EIM, we believe that post-professional residency and fellowship training for physical therapists is the most effective and efficient way to accomplish and realize the goals stated in APTA's Vision 2020 and we are committed to the task. We also believe our programs are unique in the ability to make accessible and provide post-professional residency and fellowship training to large numbers of physical therapists, including relatively new graduates, who otherwise would not be able to take advantage of this important aspect of professional development which is critical to the future of our profession.

Our programs are centered around an advanced distributed distance learning model that utilizes the BlackBoard Learning Management System for didactic instruction, group projects, and Virtual Grand Rounds. For the clinical mentoring component of our residency programs, we partner with high quality Network Partner practices across the nation that support and facilitate locally the clinical mentoring process for residents who are affiliated with or assigned to those Network Partner practices. For our fellowship program, we partner with Fellows of the AAOMPT who are eager to work together to move evidence based practice and the profession forward. The end result is that PTs who are motivated to go through post-professional education and training, but don't want to or are unable to move from their current location or place of employment, now have the opportunity to participate in a world-class post-professional residency or fellowship training program.

Here is a quote from one of our first Fellows-In-Training regarding the impact of fellowship training on his professional performance:

"When trying to figure out what I wanted to do next in reference to my professional development, I knew I wanted to do something that would alter the way I practice and change me as a clinician.  I knew after completing my DPT and becoming board certified in orthopedics that fellowship training was the next step.  I researched every fellowship listed on AAOMPT's website.  EIM was not listed as they hadn't been credentialed yet.  However, my company mentioned EIM to me and, after comparing what EIM had to offer as opposed to other programs, I was sold.  The faculty is well recognized in their research work, they are progressive, and they are change agents.  These are things I to aspire to be. 

In the last 9 months, I've become a more skilled clinician, much better at clinical reasoning, a more confident PT, and have created relationships with professionals who are always looking to better the profession and themselves, never being satisfied. 

Many great opportunities have already opened up for me and many more will likely follow due to this choice I've made.  I am excited to be a part of this program and I urge all who are considering fellowship in orthopaedic manual physical therapy to strongly consider EIM's program."

Our next class starts in June of 09. If have an interest in pursuing residency and fellowship training and would like to learn more or want to take the next step, you can find further details about our program on the residency/fellowship link of our website. Obviously e-mail and phone calls are always welcome.

Once again, thanks to the many folks who have made this achievement possible and we look forward to working with our current and future residents and fellows as well as our valued current and future Network Partner practices in order to make a lasting impact on our profession.

Sincerely,

The EIM Team

Healthcare 2.0

For a fascinating read on various potential reform measure, strongly suggest you read From Volume to Value, a publication of Network for Regional Healthcare Improvement (NRHI).

It raises some strong arguments and potential solutions for various solutions in an attempt to get away from a fee for service system bent on procedures to producing outcomes.

The most relevant examples for PT include two examples that really are offshoots of capitation (they refer to as Capitation 2.0) including Episode of Care and Condition Specific.  These examples try to mitigate the huge traditional risk component in capitation.

The Episode of Care example although not new is one whose time may be coming given lots of momentum at the federal level.  The easiest case to think of would be to reimburse a hospital for the entire chain of events-pre/post surgery, the surgery itself, prosthesis, rehab, etc.  The reimbursement from the insurance company is determined by the outcome-some aspect of a calculation that takes into account infection and complication rates, range of motion after rehab (yikes!), with some acceptable outcome instrument playing a role.  This “episode of care” capitation is highly dependent on integrated systems working together.  This poses some rather interesting questions and dilemmas given lots of systems unfolding their integration attempts over the last several years due to financial viability (hospitals unloading their home health agencies).  Where does private practice PT fit into this?

The second example of Condition Specific certainly makes intuitive sense.  A primary care physician is paid for managing a patients diabetes throughout a defined period of time (perhaps years).  A global payment is made, a patient’s monitoring and tests are part of that fee, and outcome goals that meet certain parameters (e.g. blood level of hemoglobin) may result in a bonus.

Would this work in garden variety low back pain?  A primary care physician or PT is paid for non-operative care to include defined outcomes? How can we best play in this game?

There is an enormous effort on cost of care and episodic care. Might just become the newest rage and buzzwords as the “solution’ to healthcare.  Stay tuned.

larry@physicaltherapist.com

Healthcare... What Can Make It Better?

Ever since the Summit, I have seen more and more on just what needs to happen to improve our healthcare system.

Here's an opportunity for anyone with some thoughts and a video camera... Health 2.0 is accepting 2 minute video submissions that specifically address healthcare reform.  What do you think should change and how should it change?  This opportunity is a collaborative effort between Health 2.0 and the Center for Information Therapy.  (I had no idea what the Center for Information Therapy was all about and did some checking.)  This is a non-profit organization that "... aims to advance the practice and science of information therapy to improve health, consumer decision making and healthy behaviors..."

I LOVED this statement in one of the white papers shared by the Center for Information Therapy:

" Imagine....

Imagine a world in which clinicians delivered just the right information to their patients at precisely the right moment.  Imagine that clinicians were able to focus their limited time helping well-prepared patients to put that information into perspective for their particular situations, guiding them to a decision that balances the best available scientific evidence with what matters most to them.  Imagine that the collaboration continues over time, with clinicians delivering tailored information at the right time to help people consistently make informed choices and do their right things for themselves.  You may say that we’re dreamers, but we’re not the only ones…"

It sure seems to me that the Center for Information Therapy might be interested in the role physical therapists can play in the musculoskeletal world.  Do "clinicians" have all the available options to be shared with patients that have a main complaint of low back pain?  Probably not based on the literature which seems to suggest low utilization of physical therapists in the treatment of low back pain.

I challenge someone to submit a video and plant the seed for change... the system needs to change to implement strategies that are less costly and more effective than the current delivery of care.

~Selena

If you care about the healthcare crisis, pass this on.

This is entirely old and "beat a dead horse" news, but it's worth repeating...there is far too much health care being delivered for back pain. This article says the same thing we've been saying on this blog for years (and was by no means our idea). The solution to the health care debacle in the U.S. is, in part, extremely simple. I guarantee you my mostly uneducated grandparents (who are gaining a more and more "Nobel like" genius status in my mind as I get older) could figure it out...find the stuff we spend lots of $ on and find a way to spend less $ on it.

Ok, with that simple premise from my grandparents (forget the opinions of high paid economists bearing equations...they should be utterly ignored). Where does our nation spend health care $s? It's largely on managing patients with musculoskeletal conditions, which are beginning to surpass cancer as the #1 category of medical spend. Among medical spend for musculoskeletal conditions, where are the health care $s being spent? They are mostly being spent on conditions like low back and neck pain (as this article bears out for the umpteenth jillion time).

Ok, let's keep going in elementary like fashion (my grandparents always said life was far more simple than the pundits make it out to be), exactly what are we paying for when it comes to managing back and neck pain? It stuff (nicely said, I could use more choice words) like images (ie, X-rays, MRIs, etc), drugs, and referrals to specialists who like to do expensive and ineffective procedures (injections) and surgeries (fusions and artificial disks, just to name a couple), the large majority of which most patients don't need and may even cause harm. The data, as this article points out are overwhelmingly damning of our nation spending too much $ on this stuff with far too little benefit.

Ok, to keep the Sesame Street Solution to our health care crisis going, what is the best means around this medical spending black hole? One option would be to simply stop paying for virtually all of this crap (forgive the slang, but it represents the extent to which all of this care is actually needed and beneficial in the first place), which from an aggregate level would be better than what we have now. In other words, we could simply conclude as a society that back and neck pain are no longer medical conditions that you can complain of (or at least the health care system overnight will act like they don't what a back and neck is from hole in the ground). In other words, the problem is so bad, that this seemingly draconian solution of "total denial that back and neck pain even exists" would be a formidable and legitimate solution from a societal and payment policy perspective.

However, how about a practical solution in light of the fact that our nation doesn't have the political will to start ignoring an apparent epidemic (but grossly exaggerated) overnight? My grandparents from their grave might suggest we consider routing patients to parts of the health care system that won't spend as much $ on back and neck pain, perhaps sending the patient directly to a physical therapist where the patient can receive high quality care and won't get high cost surgery, drugs, or imaging. Btw, don't overestimate my fanfare for physical therapists as the solution. There are plenty of physical therapists who still will deliver crappy, highly variable, and overutilized care (Medicare spend is increasing for physical therapy as well, but the rate of increase is far less). However, it's not nearly as expensive as the crappy and highly variable care being delivered by our physician counterparts who are incented only to do lots of procedures and interventions. My point is that at worst, President Obama should appoint physical therapists as the nation's designated "babysitter" for patients with musculoskeletal conditions. In other words, our only role is to shield patients from the black hole of useless (and likely harmful) medical spend. Think of us like the roadblocks and detour signs that keep you from making the right turn you want to make. We simply "detour" patients to low spend areas of the health care system. This would be far, far better than what we have now. Add to that of course the ability (and now supporting data) of physical therapists' ability to deliver high quality care that can curtail the chronicity of back pain, and now we have a solution that even the most crooked politician could sell as legitimate.

Why don't we see marching in the streets regarding medical spend on musculoskeletal conditions like we do on the bailouts of banks, bonus payments to AIG, etc. (because I assure you the total $ are far greater)? This too is very simple. AIG is a great target for attack because banks are perceived as evil, money grabin' SOBs so they make the perfect enemy in a down economy. Doctors are still under the halo effect that says they care more about your health than they do their pocket book, which is simply not born out by evidence (and there are plenty of individual exceptions to this sad but true generalization), hence the health care system (and in particular physicians with halos around their head) are given a political pass.

So, if you're a consumer with back pain and mad today about AIG and the fact we're bailing out loser banks, get mad about the way your healthcare $s are being spent. I assure you that more of your $s are being wasted in health care than they are in the banking business. Our health care system is kicking you in the back literally.

John

Direct Access...just watch the video, it speaks for itself

http://www.thepittsburghchannel.com/video/18891587/index.html

PT is a distruptive innovation- if we can be enabled

With author permission, Harvard Business School Working Knowledge published an outstanding excerpt from the recently released book Innovator’s Prescription:  A disruptive Solution for Health Care by Clayton Christensen, Jerome Grossman, and Jason Hwag.

Christensen, the famed Harvard Business School Professor is taking his concept and research on disruptive technology to the health care industry.  He presents a compelling view of how health care can in fact become more affordable and accessible to most people-if the right disruptions and their enablers can occur and that is a huge if given the on-going challenges of dealing with a regulatory and fee for service reimbursement climate that has easily prevented the “disrupters”.

I firmly believe physical therapists in the musculoskeletal medicine arena and in particularly low back pain given its high cost driver certainly qualifies as “industry’s simplest problems first” as the article/book refers.

Per Christensen, disruptions have three enablers: simplifying technology, a business model innovation, and a disruptive value network.  I will attempt to apply them and why I believe that PT can be a disrupter.

Enabler #1: The technological enabler transforms a technological problem from something that requires deep training, intuition, and iteration to resolve into a problem that can be addressed in a predictable, rules-based way.

PT as a technology enabler:  Clinical prediction rules (CPR) are the simplifying technology enabler and low back pain is where we have the best research and most cost-effectiveness support. 

Enabler #2: Business Model Innovation.  Within health care it has stalled in the last three decades. Regulations and reimbursement systems currently trap in high-cost venues much care that could be provided in lower-cost, more convenient business models.

PT as a business model innovation: Directly accessing patients, examining, applying CPR’s in low back pain and managing patients through application of appropriate interventions.  While not completely new it can easily be deployed and is a “predictably effective solution” to use Christensen’s language.

This blog has trumpeted the problems in regulations and recognizes how they limit innovation.  The superimposed rules by CMS and the bondage that we have to a CPT code system which is out of step with modern PT practice (namely the fact that we examine and manage patients versus forced into codes that highlight individual modalities and procedures in a stop watch mentality).  Absent those problems, the restrictions for direct access within CMS and many states further prevent us from being true disrupters.  Christensen’s pleas are right on target “regulators must beware…of attempts by leading institutions to outlaw business model innovation….What is in the interest of society most often does not coincide with the self-perceived interests of leading institutions.”

Enabler #3:  Disruptive value network. Stand-alone disruptions are not plugged into an existing value network of an industry but rather new value networks arise, disrupting the old.

PT in a new value network examples:  Many employers are contracting PT’s for direct access and paying them directly rather than thru 3^rd party carriers or worker’s comp administrators.  Virginia Mason Medical Center and their success in utilizing PT’s to wean from pricey tests is classic example of changing the traditional fee for service reimbursement.

In order to work, a fundamental change must occur within insurance and reimbursement.  As the excerpt points out it will take a much higher level of integration than has been the norm and carriers and policy will need to “disrupt themselves”.  For this to occur, employers will have to orchestrate the “emergence of this new value network, compared to the reactive nature that they have taken in the past.”

If othesr also believe that we can be “disruptive innovators” the time to get to the table and trumpet our abilities to regulators, employers, and payors is now while everyone agrees that changes in health care are necessary.  Opening the doors for PT’s to access many more patients with “aches and pains” by removing regulatory barriers which halt such innovation and working with new value networks in the  insurance/reimbursement arena can undoubtedly give us our chance to demonstrate us as one simple solution to part of the many health care woes.

Thoughts?

larry@physicaltherapist.com