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Are you Healthy?

I suppose it depends on your definition.  Dr. Gilbert Welch suggests the following definition best represents the current U.S. medical-industrial complex: Health is the absence of abnormality, the only way to know you are healthy is to become a customer.

Unfortunately nearly all of us are getting more and more medical stuff (imaging, drugs, surgery) done to us and yet we are often "no better off."   The most coherent and succinct discussion on this topic was by Dr. Welch in yesterday's New York Times.   Among the loud clamor surrounding healthcare reform we must as a nation come to a general consensus on what health means.  My current thoughts are if the insurance, pharmaceutical and hospital industries are supportive of a healthcare plan then we probably are doomed to have more of the same when it comes to ever increasing costs with minimal value in the U.S. healthcare industry.    

Tim

Value Based Purchasing and Measurements

What does Hell, Michigan have to do with value based purchasing?  Maybe nothing.  George Reeves was quite the entrepreneur until... well, until after the Civil War and the government raised taxes on whiskey to such a degree that Reeves wouldn't be able to sell his whiskey and make a profit.  Reeves and the locals believed whiskey was valuable, so they came up with a scheme to keep whiskey production alive by working as a community, sinking barrels of whiskey in the pond and lying to tax collectors.  I'm really not condoning lying to government officials or short changing the IRS on taxes, the Hell, Michigan saga is just a great little story highlighting what a group of people did too keep something they believed of value in their lives.

With Value Based Purchasing, I ask myself who determines value?  Various stakeholders will have their own perspective on "value."  Is it the government, consumers, employers, third party payers?  I would hope providers would have a large role in assisting with defining value, setting realistic standards and offering insight into processes.

Of course CMS is on a value kick.  I'm not knocking value.  I think not only knowing the services provided, but also the quality of the services, is good to know.  We do this with a lot of items we purchase, so it is reasonable for healthcare services to receive the same scrutiny.  Granted, when I read page 6 of the CMS document and think about point number 2 and then see point number 6, I do have to scratch my head.  PQRI aren't measures or even measurements, are they?  I think PQRI are more like a checklist... How does my personal PQRI list look to you?  Seriously, does it look like a measurement or a list? Measurements aren't really things you can say yes, I did it or no, I didn't do it.

What got me all thinking about value and determining value and measurements was an article I read.  Comparing the Performance of EQ-5D and SF-6D When Measuring the Benefits of Alleviating Knee Pain uses PQRI *real* measurement tools to capture the benefits and cost effectiveness of interventions.  For our profession, PQRI have nothing to do with the quality of the services provided because PQRI don't capture outcomes.  In the study listed above, I'm not sure if utility indices using scales from death to full health are the appropriate types of tools to utilize for the services we provide.  My rationale lies solely on what treatment strategies are being compared.  I would think that surgery would have a higher probability of risk (because you can die from surgery, you can have further life-threatening complications, you can have infection, you can have surgical failure) in not being as cost-effective as non-invasive treatments, such as physical therapy services.  What happens if you put physical therapy services head to head with massage therapy?  I have no idea... But, a huge risk, in my opinion, is if physical therapy services are put head to head with treatments encompassing education, advice and brochures.  Will physical therapy be deemed more cost-effective than the lowest level of intervention?  Will economic professionals really use the right tools to give them the best information?  What say do we as providers have in this journey of determining cost-effectiveness?

The devil is in the details...

~Selena

The $8.5 Million Fraud Case

Larry already beat me to sharing this information.  Here is a different perspective from Jef Henninger, an attorney in New Jersey.  For me, multiple issues come to mind.

Healthcare Reform:  The language Jef used in sharing his perspective suggests Dr. Khashayar Salartash obviously had at least one physical therapist on staff and services were billed "incident to."  The portion of fraud to Medicare was pretty close to $5 million.  As healthcare reform is analyzed, how much of a cost savings could occur with the elimination of referral for profit situations (physical therapy services included)?  Not only is there a higher frequency of use to figure in the calculation, but what about fraud?  In this particular fraud case, I would tend to believe the 1.5 to 3 year treatments were probably the red flags that created an audit.  As the auditors dug deeper, more issues were found.  Services provided by a physical therapist were not supervised... oops.  Services provided by a physical therapist were billed as surgery... oops.  Services provided in the physician office were billed as if they were provided in an outpatient facility... oops.  That's a lot of "oops."

Professional Accountability:  Think about your last staff meeting.  How transparent is your company?  Forget about referral for profit for the moment.  I bet after every patient you complete a charge sheet, or your electronic medical record determines the procedural codes and units for the services provided, right?  Do you know where that information goes?  Do you know on a monthly basis what procedural codes you use and the frequency in which you use them?  I'm willing to bet your supervisor can tell you your productivity - the number of units billed per hour and the number of units billed per day.  Maybe we need to speak up and request monthly reports on our claims data - procedural codes and their frequencies.  Is it reasonable to keep our heads in the sand and only focus on the clinical portion of day to day operations?  Is it reasonable to assume what we report for claims is what is generated on a claim?  I guess what I'm basically asking:  if the right hand knew what the left hand was doing could there be a reduction in fraud in our particular field if information was shared?

Quality:  1.5 to 3 years of treatments... need I say more?

Patient Centeredness:   In this particular situation, the patient got the short end of the stick.  I'm willing to bet the majority of the patients had secondary lymphedema.  That means the majority of the patients either had surgery, had an infection or were fighting cancer.  (Here's some quick info for those of you not completely familiar with lymphedema.)  Fraud cases always focus on the money... and it isn't just a money situation.  The lives of all the individuals in this particular case were obviously affected.  The patient had no idea the surgeon was focused on profits, had no idea the pleasant physical therapist probably wasn't competent, and had no idea 1.5 to 3 years of treatment was unacceptable.  What does it literally mean?  The patient probably still has a sausage of a limb due to a failure in the system.

~Selena

Physical Therapists Pledge Billions in Savings to Health Reform

At least that is what I am hoping that our national press release will say.

Following in the footsteps of pharma and hospitals, it is time for PT’s to really get our name in the healthcare debate-let’s pledge billions in savings.  This political tactic has bode well for the others that have done so.

Pharma has pledged thru supposed price reductions that their savings amounts to $80 billion or less than one-tenth the projected cost of healthcare reform.  To put PT in perspective, the outpatient medicare dollar amounts to roughly 3 billion in total or one-two hundred and twentieth of the cost-but let’s not quibble over a few decimal points-in fact, let’s pledge 100% of the last fiscal year’s spending.  (side note:  PT expenditures are less than 2% of the CMS budget and actually decreased in spending per CMS data-what other provider group had actual decrease in cost to CMS?) 

Hospital strategy of $155 billion is a little more crafty. It is a supposed cut in pay and less subsidy for underinsured under the premise that everybody will have health insurance.  The point in both pharma and hospitals is that the numbers are purely fictional but represent their “commitment” to healthcare reform. Let’s do the same!

One main tenant of our savings that is unlike the sham estimates of pharma and hospitals, we won’ t won’t pledge thru fee schedule reductions.  There isn’t anything to give here and in addition we can’t withstand the 21% forthcoming reduction due to the SGR calculation-neither can other providers.  We also will not pledge a hard and fast number-just “billions” but we will provide some logic and rational to our calculations.

I am not a healthcare economist but it would only make sense to engage somebody to pull together some pretty straightforward estimates.  Just off the top of my head, I can think of three areas where we can save billions:

-Eliminate conflict of interest in PT.  Calculate per CMS data the amount of PT billed either incident to service or by PTPP performed within a physician’s office.  Take 80% of that amount figuring that at least 20% of the patients would get referred to a non conflict of interest party.  Apparently, the government already has all kinds of data on overutilization in imaging centers that are physician owned—am sure that there is some consistency in the factor of increased referrrals. 

-Cost effectiveness.  Look at highlighted savings on low back pain by the Virginia Mason’s of the world and extrapolate that to 8.5% of the projected number of patients in the medicare and expanded government system (per previous CMS data 8.5% of the 43 million beneficiaries accessed outpatient PT).  This savings estimate ought to include the reduction in direct imaging, pharma, and surgery that would result from using PT’s as primary musculoskeletal screeners.  In fact, calculate the incidence between surgery between the military and civilian sector and that should logically point to a method of calculating the difference as that is how the military uses PT’s-as force multipliers due to the fact that there are not enough primary care MD’s and orthos.  Cost estimates in knee arthritis, prevention methods for falls and balance can also be made.  Let’s also make a plea to our Congress to look no further than the military model as the place to put PT’s as access for musculoskeletal complaints will be a potential bottleneck with the addition of approx 45 million who are currently without insurance.

-Massive changes in fee schedule.  Take the entire CPT code system that applies to PT and get rid of it.  There are only a few providers left that aren’t in the E&M system and we are one of them. Put us in there and move to a 3 code system that bundles everything together into a patient complexity model that is determined thru PT evaluation and supported by a standardized outcome system that acceptable to PT’s-there are only a few of them out there.  Cost savings would be immense as those who drive increased units thru the use of interventions that have zero evidence are eliminated.  We could even agree to an episodic case cost within 5 years once bugs and prototypes are worked out.  (side note: as I have written many times, it is a lot easier to suggest changes in the CPT system but changing them is altogether different.  Even the AMA is being heavily criticized by their own thru Sermo who is calling them the biggest risk to physicians in part due to coding)

As a trade off for saving billions, we of course will have to have significant regulatory changes to include direct access, elimination of plans of care, cap, explicit provider rules (let’s settle on allowing us to use our state practice acts), PQRI (since we will agree to an outcome based complexity model for payment), and the 8 minute rule and coding complexity issues including modifiers would be a thing of the past.

Yes, many will question our savings calculation and like our pharma and hospital counterparts, we will not admit that they are bogus!

Let’s do it!

Thoughts?

larry@physicaltherapist.com

Grandpa Was Right

Shortly after graduating from PT school (1985), I remember telling my Grandpa that he needed to go get checked for an ailment he was complaining about. He told me with great sincerity “Rob, going to the doctor can be hazardous to your health!” I have often regarded his statement stemming from his being born in 1915, a time when being treated by a physician often meant you had a 50/50 chance of being better off because of it. However, as the years have gone by I am more and more convinced that his statement is a lot more applicable today than I once thought and these recent publications indicate why.

Although the results of two recent studies examining the practice patterns and beliefs of orthopedic surgeons and family practitioners were not totally surprising, it still takes one back a bit and reminds us of the significant potential role that PTs could have in the management of LBP and the enormous savings in both costs and suffering that could be realized. These two publications yank some pants down in a major way for all to see that orthopedic surgeons and general practitioners in Australia or Israel are wearing neither boxers nor briefs when it comes to the management of LBP.

Title: Orthopaedists' and Family Practitioners' Knowledge of Simple Low Back Pain Management (Finestone AS et al Spine. 2009;24:1600-1603)

"Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs. Significantly less importance was attributed to patient encouragement and reassurance by the orthopaedists as compared with family physicians.'

Conclusion: "Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice."

Link to the abstract: http://journals.lww.com/spinejournal/Abstract/2009/07010/Orthopaedists__and_Family_Practitioners__Knowledge.14.aspx

OK, those are the results from just one study. Fair enough. However, similar shortcomings were found in this study of over 3000 general practitioners in Australia with one important exception: physicians with a special interest in low back pain were MORE likely to believe that complete bedrest and lumbar radiographs are useful in the acute management of LBP and associated with poor patient management.

Title: Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain. (Buchbinder R et al Spine. 2009;24:1218-1226)

Conclusion: “A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community”.

Links to the abstract:

http://www.ncbi.nlm.nih.gov/pubmed/19407674?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

I wonder what the results would be if these two studies were replicated in the United States? I also wonder what the results would be if a similar study was conducted involving physical therapists’ beliefs and practices with regard to current best evidence in the management of acute and chronic LBP. Are we confident we would be proud of the results or left with our face a dark, beet-red color?

Well, the good news is that there is plenty of opportunity to fill a void by working to ensure members of our profession are utilizing current best evidence in the care of LBP and marketing ourselves as the Best First Choice for patients with LBP (not to mention non-operative musculoskeletal problems as a whole). The results on our health care system from that one area alone would ensure us a welcomed place at the health care table. How about moving forward with that?

It isn’t because we don’t have evidence related to the management of LBP that, when implemented, results in better outcomes than the passage of time or other comparative treatments. Rather, we simply don’t implement the evidence we have available.

This non-sense simply has to change….and soon.  Carrot, stick, or some combination of both, whatever it takes.

Rob

Happy 4th of July From EIM!!!!

All of us in this great country have so much to be thankful for that we actually need to take the time and, well......be thankful!! 

It has been over a year now that my daughter has returned safely from a tour of duty in Iraq.  In addition, many students that I had to privilege of training over the years as well as colleagues and good friends have been "over and back" also (BTW....Welcome Home Deydre Teyhen!!!).  Unfortunately, that is not always the case. Such is the price of Freedom and Liberty and it is these noble sacrifices that remind us that Free isn't "free".

 

I am definitely going to take the opportunity to fire-up my grill this weekend and partake of the wonderful 4th of July activities that we in the good 'ol USA enjoy.  However, I will also be spending some time reflecting and being thankful for the many things that are precious to me personally and to us as Americans corporately. I encourage you to do the same you begin to prepare to enjoy this special weekend. 

Although it is July 3rd today, all of your friends at EIM want to wish you a Happy 4th of July!

Rob

CMS Proposal for Policy and Payment Change in 2010

What do these potential changes mean for PT?  I haven’t a clue-do you?

Some of my takes:

-we are still looking at a 21.5% reduction in 2010 but it might actually be more given the “redistribution” in codes which have to be balanced. This might mean that it could be a more draconian cut than 21.5.  On the other hand, we have been exposed to supposed cuts since 2002 and yet a reprieve has always occurred.  The whole SGR has faulty premises acknowledged by almost everybody and in the context of bigger reform, I would have a hard time believing that something won’t change

-looks like specialists won’t be getting bigger bucks for “consultation” and will have to take the E&M route and this reduction will increase primary care type of payments by 6 to 8%.  (note for file:  check again why PT’s are one of about 3 practitioners left that cannot bill using E&M)

-in what might be the most crafty strategy that I have ever seen CMS devise, they are going after referral for profit imaging by decreasing payments and wanting outside accrediting bodies to credential imaging services!  There are other regulation suggestions on this 2 part initiative and MedPAC and GAO have obviously substantial data that suggests overutlization of these hi cost drivers.  The big question for us as PT’s-why can’t they extend this same philosophy for other conflict of interest scenarios like physical therapy centers?  Could an MD owned PT clinic withstand even rehab agency survey yet alone something more onerous like CARF? (note for file:  find out why our national association doesn’t list this as a hi priority for their healthcare reform position)

-PQRI, the voluntary reimbursement cut that almost nobody is doing is going to expand the number of measures and seek the ability to utilize systems contained within an EMR in an effort to streamline efficiency

While this is not an exhaustive list, these appear to be the major points of the proposal.  keep in mind that it must go thru comment periods and will undoubtedly have major changes in it prior to implementation at some level in 2010. Likewise, while all this is occurring, the national debate and potential massive reform legislation continues.

larry@physicaltherapist.com