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Medicare is the Public Option for Seniors

I have posted many times that the financial windfall via subsidies for private insurers providing Medicare Advantage is a huge crock.  These posts are listed here, here, here, and here.  My biggest criticism is that private insurance companies then take this subsidy and use it for significant marketing costs and tie it to their commercial customer base and strong-arm providers to accept fee schedules below medicare rates and getting enhanced profits from this arbitrage and government funded gimmick.  With recent enrollee numbers exceeding 10 million in the medicare advantage world (about 25% of all medicare patients) the subsidy (not Medicare Advantage) would be eliminated under Obama’s health plan to the savings tune of about $177 billion over ten years.

While there is much in the current HB 3200 I find distasteful, eliminating excess payments to private insurance companies is not one of them.  While I am not being against private companies administering medicare, it makes no sense to pay them at a cost higher than the government can do it themselves.  It would be akin to paying your neighbor’s 12 year old more for cutting your grass than you would pay your own kid.

This $177 billion is both the centerpiece for assisting to pay for Obamacare as well as a current source of controversy.  According to Obama, savings like medicare advantage and others not wholly identified would pay for approximately 2/3 of the reported 900 billion of the plan costs.  As a general rule, when the government says that they will eliminate waste, I get downright suspicious and ask for evidence of their success in other areas.  To put $423 billion into perspective-which is the amount to get to 2/3 when adding savings from medicare advantage, you would have to eliminate outpatient therapy completely for almost 106 years to get that projected savings (although I am sure that even with PT currently at 2.2% of the medicare budget, they will find a way for us to contribute our share). 

The political controversy stems around David Axelrod’s “viral” email in which he states that “it’s a myth that health insurance reform would be financed by cutting medicare benefits” erstwhile President Obama is at town hall meetings about “eliminating waste” including Medicare Advantage.  Karl Rove in an op-ed highlights this apparent disconnect by going into a rambling discourse on how eliminating the medicare advantage subsidy actually cuts benefits-something that makes absolutely no sense at all and actually his position is the real “myth”.  If eliminating the subsidy causes enrollees to go back to government medicare, how is that a loss in benefits?  In fact, you might call Medicare the “public” option for those above 65 who have the right to enroll in Medicare Advantage if they believe the quality of care, benefits, and value is better than medicare. If private insurance companies find the business profitable and it often is if they are successful at cherry picking the healthy seniors they will continue to play.  Because privatization of medicare is a cyclical product in the last several years, many will exit and perhaps others will enter.  Isn’t that the meaning of true competition?

Thoughts?

larry@physicaltherapist.com

Is This Really Research 2.0?

I will assume many of you are familiar with the spit parties of 2008.  23andMe basically provides reports from DNA analysis of your spit.  That's all fine and dandy, I suppose.  I'm not sure about the validity or reliability or accuracy of the reports, so at this point in time, there may be issues in customers believing the reports to be 100% accurate.  23andMe has moved into being more than just an "informational" kind of company to a company that stores the genetic information for internal research AND to share with other companies.  I couldn't find any information anywhere as to the "other companies," so I have no clue the focus of the "research 2.0" occurring.  If the profiles are being used to assist in recruiting subjects, then a potentially helpful relationship for this endeavor has been created.  If individual profiles begin to have data dumped into third party payer systems to determine premium rates for subscribers, this would be problematic.

Another company, PatientsLikeMe maintains a database currently consisting of 40,996 individuals who have subscribed to the free service.  In June, UCB (a Belgian pharmaceutical company) partnered with PatientsLikeMe.  UCB will obviously have access to the database.  The supposed goal was for UCB to enhance the ability to learn how drugs affect patients.  Now, I don't know about anyone else, but I could easily envision instead targeted information being provided to the individuals in the database - kind of like how Amazon knows the kind of books I read and sends me frequent emails on what it thinks I will like.

Since nonmembers could look through PatientsLikeMe, being the curious person that I am, I did a quick assessment.  Not all patients reported within all the categories.  This leads me to wonder... did a particular treatment not happen OR did the person just skip filling in information?  I also don't know how the information was provided as to whether there could be reduncancy in information.

What if... What if various medical professionals used the information (instead of private companies)?  For example... take fibromyalgia.  When I did this search there were 5,467 patients with this condition with recent updates.  Of those patients, you can see for "physical therapy" there are a lot of problems... maybe the patients didn't know what physical therapy was??  (How did chiropractic fall under physical therapy?)  Putting that aside, the main intervention reported by patients was "massage therapy."  Only 2 reported physical therapy for endurance, resistance and strength, 5 reported dumbells, 2 reported theraband and 1 reported kettleball (under the physical therapy treatment category).  Hmmm... from my opinion, our profession has issues in how patients are being treated because massage therapy is not evidence based for this particular type of patient.  Okay, I know maybe patients get confused, so I looked further and browsed the treatments and saw there was a category for exercise.  Exercises reported were mainly stretching and walking and stretching. 

Reality is the biggest glaring issue I saw was that we have research supporting the role of physical therapists for this condition.  For 5,367 patients, a huge, huge majority are not receiving adequate care!  Every single one of them should have reported some form of exercise.  

I wonder... if Pfizer entered into a partnership with PatientsLikeMe focusing on patients with fibromyalgia... I wonder if after 12 months of partnership if there would be a substantial increase in patients reporting Lyrica as a prescription drug?

Can we use "Research 2.0" to improve the care for patients?  Could we set specific goals to see an increase in utilization of physical therapists for appropriate patients?

~Selena

photo by keepthebyte via Flickr

Smokey sings the blues

Sometimes you need graphic evidence...and sometimes you just need graphics. As a founding feline of the American Academy of Orthopaedic Manual Physical Therapists, I am taking a particular interest in the recent efforts to revamp our beloved AAOMPT logo. While the stylized spinal segment logo means a lot to many of us, it may not appeal to the public at large. I respectfully suggest that the apparently disarticulated spinal segments surrounded by  a shade of burgundy suggesting the color of blood may be more appropriate for an organization of spine surgeons, not manual physical therapists. Why don't we emphasize our manual paws-on approach with more appropriate graphics and ditch the burgundy altogether? My first choice of color is, of course, gray, but I will compromise on a dignified shade of deep royal Blue Devil blue. Herewith is my submission...let me know what you think...

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Check Out EIM's Upcoming Upper Extremity Courses!!

"Overall, my practice will change tomorrow, and I feel much more confident that I have
the tools necessary to effectively treat my patients."
--EIM CE Student

EIM offers over 25 online and hands-on CE courses that enhance practical skills while granting
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For more course info click here and see below for upcoming hands-on
Evidence-based Examination & Selected Interventions
for Patients with Upper Extremity Disorders courses:

September 19/20       Alamance Regional Medical Center                    Dr. Jason Rodeghero
                                  Burlington, NC

September 26/27      San Luis Sports                                                   Dr. Rob Wainner
                                 San Luis Obispo, CA

September 26/27      ProAxis Therapy                                                  Dr. Jake Magel      
                                 Greenville, SC

September 26/27      ProRehab                                                            Dr. Jason Rodeghero
                                 Evansville, IN

September 26/27     Texas Physical Therapy Specialists                      Dr. Brenda Boucher
                                 Austin, TX

October 3/4              AthletiCo                                                               Dr. Joshua Cleland
                                Oakbrook, IL

October 3/4             Benchmark                                                            Dr. Robert Boyles
                                Atlanta, GA

October 3/4             ProActive                                                               Dr. Amy Kirkland
                                Syracuse, NY

The Real Source of Medicare's Physical Therapy Problem

For the typical readers of this blog, please breath a sigh of relief.  Physical Therapy to medicare patients delivered in a freestanding PT owned practice, outpatient rehab facility, and even the few CMS reported users still left billing “incident for service”, you are not the source of CMS therapy expenditure problems.  While it is easy to get the impression that you are wearing the CMS “bulls eye” due to the overabundance of superimposed rules, regulations, plans of care, caps, and now RAC’s, one only has to look the recently released 2007 CMS rehabilitation data to find the real culprit (fully revealed after some background and data).

The report now by a different contractor than what was in the 2006 data and prior gives us all kinds of “fun facts to know and tell” in case you get stuck at a rehabilitation trivial pursuit party.  You get spending breakdowns by setting, sex, age, and state.  If you live in AK or ND, you will be glad to know that you are in the top 2 least costly states. What setting bills the highest percent of massage? That would be hospitals.  Want to know how many PT providers per 1000 medicare part B enrollees?  5.73 if you live in Maryland and .28 in MN. Impressed yet?  How about the big surprise that there are way more females getting PT than males?

Some good, some not so good, and some interesting tidbits about the 2007 report:

-According to medicare trustees report, overall spending increased 5.7% and Part B spending 6.3% from 2006 to 2007.  The good news is that Part B PT increased slightly below 6.2% or about $190 Million to $3.2 billion.  However, overall therapy costs increased 7.5% with OT and SLP bringing in double digit increases and an overall cost of about $4.2 billion.  The change in dollars per user is probably the most useful reference point in that it adjusts of changes in patient volume from year to year.  In this regard there were actually less number of PT users in 2007 from 2006 but cost per user increased 6.1% to $836 (well below the cap!).   Unfortunately, there is an inflation of overall annual therapy cost per user of 7.9% which is above medicare inflation and is probably raising more than a little red flags to our medicare friends.  Keep in mind that in the big picture of things about 2% of medicare outpatient spending is on therapy costs which makes you wonder why in the world they aren’t paying any attention to us in the first place. 

-If you look at the CSC data from 2004 and compare it to 2007 RTI data, you will gain the perspective of the impact of various payment policies (e.g. 8 min rule, exclusive provider stuff, caps) and you will see that if the goal was to decrease spending on a per user basis, these rules worked with PT user from $864 in 2004 to $836 in 2007 for a reduction of 3.2% (not factoring inflation which would lower it more).  In fact, in aggregate (PT, OT, SLP) per user is essentially unchanged between 2004 and 2007 despite significant increase in number of users and providers.

-The number of providers for physical therapist independent practice (PTPP) increase by about 2,500 from 2006 to 2007 but increased by 11,000 between 2004 and 2007 in all likely accounting for both MD practices billing as PTPP as well as growth in private practice  MD’s billing PT “incident to service” went down again in 2007 with an aggregate loss of 21% since 2004.  Hospital number of provider went down slightly between “06 and “07 and is down 8.4% since 2004.

-Hospitals market share of outpatient PT continues to erode.  Anybody that really thinks being exempt from the cap is a competitive advantage for hospitals is hopefully not teaching any business courses.

While we can spend oodles of time on alternatives to the cap and other medicare nuisances, why not consider going after the obvious culprits of medicare spending?  If data demonstrates that one particular setting is grossly over represented with spending amounts on a per user basis, wouldn’t it make sense to focus on that setting? 

The obvious place to turn is skilled nursing (SNU).  On a per user basis, the average case is double what it is for outpatient PT independent practice!!   The per user spending for both therapy costs (and PT only as the data can be modeled) SNU is roughly $1720 per user versus $870 for PTPP!  In fact, the reason for spending increases between 2006 and 2007 is clearly the increased use of more than one discipline-guess what setting that occurred most in?  Is it reasonable to assume that patients seen for part B outpatient in a long term care facility are twice as severe as all others?  The only rational data to support some cost difference is the age of the patient is greater in SNU, however should it be double and on average exceed the cap?  While CORF is roughly the same on a per user basis, their overall number of users isn’t significant to factor into the overall analysis and CORF’s are being removed faster than auto clunkers.  Why are all medicare outpatient settings suffering due to maldistribution by essentially one setting?

I don’t really believe that SNU cases should be anywhere near twice that of private practice.  Are there reasons for this?  Does the fact that many contractors most of whom are large players in the busines get paid a % of collections for part B?  They aggressively contract against their competitors for part A SNU on a per minute basis.  Do they expect to get it back on Part B thru co-treatment and overutilization?  Do they have sophisticate systems for maximizing part B patients?  Isn’t % of collections contracts in all other settings considered a conflict of interest?

If CMS is really serious about decreasing therapy costs, they would implement separate rules and alternatives to the cap with SNU than everybody else. Why isn’t this being discussed and debated at a greater level on a national basis?  Is the long term care lobby, namely NASL that powerful politically?

Thoughts?

larry@physicaltherapist.com

Transitional DPT Truths

I have a confession to make. I have an non accredited (unaccredited?) tDPT.  This is simply because the tDPT program I earned  thru completion at MGHIHP is a completely unaccredited program. I must also confess that when I did this several years ago, I knew it wasn’t accredited but I did it anyhow.  I already feel better now thru this public declaration.

For the 11,000 or so PT’s who have received a Bachelor’s or a Master’s who then bought into the vision and movement of physical therapy to a doctoring profession by enrolling and completing a tDPT, none of yours are accredited either!  In fact, using terminology like “accredited” or “unaccredited” for tDPT is like asking Tiger Woods if he is licensed to play golf-it’s just not the right terminology.

What I have come to find out unwittingly is that the tDPT might be the most misunderstood concept within our own profession.  There is no accreditation, credentialing, or external approval for tDPT’s by design.  It is an aberration in the education circles as there have only been a handful of professions that have migrated from bachelor’s to master’s to doctorate.  Delving into those, namely optometrists, podiatrists, pharmacists, audiologists is actually quite interesting since there are few similarities in the way that each transitioned.  My favorite is the Podiatrists who woke up one morning after the good “doctorate” fairy sprinkled “initials” dust on them and they were all of the sudden Doctors of Podiatry.  Perhaps the optometrists were the most crafty-simply transitioning by name-if you happened to graduate before they converted to entry level doctorate degrees, you were forever labeled an optician.  Pharmacists, Audiologists, and us have been triplets of different mothers-choosing to be hybids of one another.  Frankly, APTA’s tDPT advisory group and the subsequent development of the PTET for very good reasons utilized a very similar framework as the Audiologists.  Admittedly, with 200+ PT programs and varying requirements by State’s Boards of Regents and licensure boards, it would have been impossible for PT to have a consistent across the board method.  Great credit goes to APTA by defining a preferred curriculum model and further revising it to provide guidance for those educational institutes who are obliged to follow. 

The tDPT concept is really very simple. Provide education in core competency areas that have been added since bachelors and masters to “true up” those that are now part of the entry level tDPT.  Obtaining a tDPT was never meant to be a requirement for licensure which is one of many reasons why an outside agency like CAPTE or anybody else would never waste their time accrediting. It is a post professional educational program with perhaps a lifecycle of 10–20 years.  Within the 2020 vision of PT being supplied by clinical doctorates, the tDPT is to bridge those PT’s who currently have a bachelors or a Masters to the doctorate level and have it become the de facto for our profession.  It is a “clinical” doctorate thus not necessitating extensive research projects nor any required publication or dissertation.  Please note that this means the tDPT is not a “scholarly” degree meant to prepare one for a teaching position within a PT program. Those so inclined towards that should prepare thru a traditional PhD program or the like.  It should also be noted that the designator for physical therapy is PT and not your degree-this may change in the future.

Because physical therapy is a hobby for me as well as my vocation, I decided to do an extensive current and historical check on the way more than the reported 70+ tDPT programs.  Frankly, there are so many that I am sure it is impossible to keep them up to date on APTA’s website.  Not surprisingly, the most common programs are those that already are PT degree granting.  They have in many cases provided a method for their prior graduates to obtain their DPT by allowing them to get the coursework that was added to the entry level DPT program.  They understandably limit the eligibility to their prior graduates.  Some have already ceased being in existence having reached their goals. There are also numerous programs that are based out of university’s that have transitioned their entry level to DPT and allow licensed PT’s from any program to enroll. Many review portfolios and then determine the necessary coursework that must be completed to earn the tDPT.  I personally chose to go this route with MGHIHP’s because I was impressed with their process, director, instructors, and completely online opportunity. As you can imagine, many programs are completely online, others are completely in residence, and yet others are a combination of both.  The critical component is whether they fulfill the intent on the “gap” in knowledge/competencies between B.S., MPT, and fulfill the preferred curriculum model as espoused by APTA thru member consultants representing academia and practice. 

Unfortunately, it then gets a little erratic.  If you do enough searching, there are clearly diploma mills for tDPT including those that give you the tDPT if you take enough of their traditional CE courses without respect for the intent or the model of tDPT.  I even found one that is only a tDPT if you are a foreign trained PT.  Ironically, they don’t even list their courses!  There are also tDPT courses that have you “specialize” in a particular area.  This is a little confusing for me because that is not the intent of the tDPT but it does allow one to essentially combine courses in fulfillment to the curriculum model and additional one’s that are of interest to perhaps allow focus on an area of study.  It is also difficult to tell in today’s world whether the organization is “allowed” to be degree granting.  Although there is no accreditation for tDPT, almost every state has a licensure of sorts for educational organizations. Perhaps anybody can call themselves a “university” the tell tale sign is if they have gone thru the process and rigor within their jurisdiction to actually allow them to do what they do.

What I find the most difficult to understand is the lack of popularity of the tDPT.  Given change in technology, there is simply no excuse for not obtaining if you really believe in our profession’s vision. While cost can be a factor, there are lots of very good programs that allow you to obtain it while still maintaining your work/life balance.  While we will never transition 100% of PT’s to DPT’s like the podiatrists, there are opportunities to move large numbers to DPT and provide for unprecedented elevation of the profession. The approach that we have taken at EIM’s Institute of Physical Therapy is to couple an executive management curriculum with the necessary clinical courses detailed in the preferred curriculum model. The students simply take the necessary and same clinical courses that our APTA credentialed residents and fellows.  While it is clear that a good portion of our executive management folks are not doing day to day patient care, we maintain that the knowledge base must fulfill the intent and model of a tDPT such that pharmacy, medical screening, radiology, and EBP courses are mandatory after determination thru a portfolio review that the candidate is a fit for the tDPT.  We have even partnered with the Private Practice Section of APTA to create this opportunity for the many that want a tDPT but also want to enrich their practice’s operations.

 Thoughts?

larry@physicaltherapist.com

Self-Referral in Healthcare = Costly Conflict of Interest

The cat was out of the bag after Atul Gawande shared what happens in McAllen, Texas.

The American Society for Clinical Pathology knows just how damaging self-referral can be.

The American College of Radiology is against in-office self-referral.
 
The United States Government Accountability Office knows self-referral may not necessarily equate to better quality of care and knows the underlying rationale for physicians choosing to include additional in-office services.  (hint, hint... six letter word that begins with P and ends in T.)

The American Physical Therapy Association's (APTA) recent press release indicates they know!  Finally...  "APTA urges Congress to take action to remove physical therapy as an 'incident to' service in physician offices and to tighten Stark II referral-for-profit regulations to eliminate financial incentives that contribute to high physician billing of physical therapy services." 

I hope the APTA will do more than just submit a press release.  Will the APTA join with other groups to eliminate self-referral?

~Selena

photo by titancatwoman via Flickr