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Physical Therapists and Contracts

Our family's traditional stocking stuffer extravaganza took place last week.  For those of you unfamiliar, this event is highlighted by driving for 10 minutes to find the last parking space at the mall, entering the mall and hearing Christmas music, negotiating the dollar limit for the stuffed stocking while eating the grease at the food court, determining the time limit to accomplish the feat, and of course, exchanging last minute wishes between our kids.  This tradition is for our kids and they are solely responsible for each others' stockings.

As our daughter and I embarked on our mission, we came upon this sign.  It made me pause and think.  This sign could be the future of physical therapists.  Really... John and Larry have shared (multiple times throughout the years) the contracts coming down the pipes.  If physical therapist business owners continue down the path of making life easy for referral sources by participating with all third party arrangements and accepting contracts that pay poorly because something is better than nothing, the one change that just might have to happen is reflected in this sign. 

How many physical therapists do you know that love their career so much they they would be willing to be paid $24.99/month? 

~Selena

A Few Last Minute Physical Therapy Holiday Gifts

Although I was hoping to receive a Christmas gift that I think would be really sweet-a Fathead Sage Hero, it hasn’t appeared on the market yet-however, under the proviso that it is better to give then to receive, I thought I would hand out a few gifts-or at least gift wishes:

To Medicare Patients:  The gift of direct access which is already available in most states (other than “the land time forgot” like Indiana).  It is clear that after many years of giving it the “old college try” our strategy of convincing legislators is not working-time to get patients as advocates (and by the way, a demonstration project in rural areas should not be considered a victory-partial or otherwise).

To all PT’s and PTA’s including students: The gift of a new “Hippocratic” oath which would include a signed attestation signifying that you will not be employed by a physician. This is a legislative battle that is not being won currently so perhaps one based on conscious appeal will do it.

To State Boards of Physical Therapy:  The gift of common sense, avoidance of “groupthink”, and a reminder of who are your customers.  While I am sure that “penalizing” a private practice physical therapist is somewhat of a Christmas present in and of itself, you should realize when you penalize therapists for taking an “open book” jurisprudence exam (of which a 5^th grader filling in random answers until a passing grade is obtained) a few weeks late it sets in wheels all kinds of consequences including obscene financial penalties, dealings with other state boards, re-filings, letters, etc. etc. 

To legislators:  The gift of discernment.  You can’t add 41 Million people to the healthcare system and save money-unless of course you take it from providers which will force them to opt out of seeing the very patients that will need it most.  Any public option is not “pro competitive” and will look like GMC’s free 72 month financing versus Ford’s finance rate.  While healthcare reform is necessary and imperative, doing it without significant public endorsement is a mistake.

To health insurers:  The gift of understanding.  You can’t pay physical therapists below their costs and not expect them to show up on your doorstep.  Physical therapy eliminates downstream costs of imaging, surgery, and drugs. In actuality, paying physical therapists more will save you money as some have already experienced.

To private practice physical therapists-particularly in Calif: The gift of acumen.  You don’t have to accept unilateral contracts at 30–40% below your rates just because a 3,000 gorilla says so.  Use the power of patient advocacy and community to reverse their dumbfounded decision.

To the PT’s and their staff participating in EIM’s executive management program:  The gift of continuity.  You already have received the gift of proactivity.  WSJ ran a recent full page of articles on MD’s clamoring to get business education-you beat them to the punch.

The To our readership:  The gift of acceptance-particularly of our appreciation for your contributions toward the “cause”-elevation of our profession.  A big thank you and Happy Holidays.  It’s been a fun, action packed year.  2010 will even be better-let’s make it so.

larry@physicaltherapist.com

 

EIM 2nd Annual Elevator Pitch Competition!

Many submitted to EIM's end Annual Elevator Pitch Competition, but not everyone could win.  Here are some of the videos that were great but didn't make the top three.  Also, EIM will be running the competition again next year so start thinking creatively!

http://www.youtube.com/watch?v=Ax0g1Jr2Ick

http://www.youtube.com/watch?v=cskJb0Fe69k

http://www.youtube.com/watch?v=fHNuEom3ruI

http://www.youtube.com/watch?v=VxyyryOXUDo

http://www.youtube.com/watch?v=Sq-1UcLtXsk

http://www.youtube.com/watch?v=_KKxXE6p9ik

http://www.youtube.com/watch?v=88_4_zdfkhU

http://www.youtube.com/watch?v=Rk11Uo2sTMc

http://www.youtube.com/watch?v=ZGtMCBXAqnE

http://www.youtube.com/watch?v=5XW12dAdjAE

http://www.youtube.com/watch?v=1pUbjzJR9CU

http://www.youtube.com/watch?v=hLDVfm01pJg

http://www.youtube.com/watch?v=7WG-riGXZMk

http://www.youtube.com/watch?v=5WgGsLEZZjM

http://www.youtube.com/watch?v=QnBaWQJMyPg

The Gift of a Physical Therapist

'Tis the Season… Christmas.  Are you sharing your gifts this Christmas?  Your gifts should never remain on a shelf.  They should be used as often as possible.  Here's my version of the gifts you have to share this Christmas.

          providing

C - Cost-effective, Compassionate Care

           with

H - Healing Hands

           focusing on

R - Rehabilitating and Restoring

           while being

I - Illuminatingly Industrious

           and

S - Salubriously Sage

           spotlighting

T - Therapeutic Treatments

           including      

M - Manipulation, Mobilization, and Movement

           practicing with

A - Abounding Accordance

           while

S - Synthesizing Skill and Science for a Solution

 

Merry Christmas!  Wishing all of you the best.

 

~Selena

More Payer Non Sense from our "Beloved Friend" United Health Care

While we're on the topic of criticizing the recent non sense from Blue Cross in California, I couldn't resist the opportunity to comment on UHC's recent change in payment policy declaring that they will no longer pay for any traction, cervical or lumbar, clinical or home (to take effect Jan 1). I can certainly appreciate that not all patients benefit from traction; however there is clearly mounting evidence for a subgroup of patients that benefit from this form of treatment (here, here, and here), particularly cervical traction. On the one hand, what's the big deal, right? You're only getting paid $35-50 now anyway, so what's another kick in the pants to you from UHC...we have grown to expect this type of non sense from them, never mind the extreme disservice this does to their customers, largely employers who should leave them in mass.

Please forgive my bluntness and direct tone, but this is the type of payer non sense that drives me nuts, primarily restricting the use of beneficial interventions amongst the very group of providers (physical therapists) who offer the most hope for solving the health care crisis in the MSK arena.  Let's presume for a moment that traction is completely useless for all patients (which it is not). But even if it is, this is an intervention used primarily in more chronic patients with radiculopathy, a group that is far more at risk to consume downstream health care costs if not managed effectively with less expensive non surgical interventions. Why in the world would you take away even a remotely beneficial intervention (and again, there is mounting very good data to support the benefits of traction for a subgroup of patients with spinal disorders, particularly cervical) that is non invasive, less expensive, and may curtail downstream health care costs!!!???

I am assuming UHC is going to hide behind the “there is no double blinded RCT mantra for traction” in defending this (I could write the defense I have seen it so many times). If my assumption is correct, then when is UHC going to come up with a similar policy that no longer pays for spinal fusion surgery or practically any of the other more expensive, less effective, highly invasive, and far riskier medical procedures that are done in droves...the real problem that plagues our health care system? All of this is a collective punch in the heart to those who offer the best solutions to real, meaningful, and lasting health care reform and is another example that things will continue to get worse before they get better.

Happy Holidays, UHC.

John

Clueless in California-Blue Cross Way of Improving Health

There is nothing worse than a health insurer taking a slam at an entire industry.  There is nothing better than seeing grass roots efforts to point it out.

The former was done by Blue Cross of California to its physical, occupational, and speech therapy providers via a letter and informing them that their reimbursement is being cut as of Feb 1, 2010 to a maximum of $75.  Additionally, in only ways that immoral health insurers understand, a non negotiable standard form contract has to be executed or the clinics will no longer be able to see Blue Cross patients.  keep in mind that Blue Cross controls the market as California’s largest private insurer-by far.  This action is akin to Marcus Welby coming home to tell his family that his income has just been cut by 40%.

Citizen marketing and raising awareness about this issue is the unforeseen action that Blue Cross (whose stated mission is to “improve the health of people we serve”) probably didn’t anticipate.  Check out this blog post on The Huffington Post-perhaps the world’s most read blog.  I hope that California physical therapists take the same action that they did in NY when something similar happened-march together and force a meeting with their CEO.  Here are a few things that he should know:

-Your customers are employers.  When you decimate an entire industry, you might want to inform them before you inform the providers.  If you had done that, you might have refrained from slamming PT’s with such Draconian cuts.  Your customers have had positive experiences with PT’s. 

-PT’s have been shown to be an integral solution to musculoskeletal problems-particularly hi cost drivers like low back pain.  In Seattle, treatment time for LBP has been reduced from 66 days to 12 using PT’s as part of solution. 

-Enlightened insurance companies have INCREASED fees to physical therapists because they have focused on cutting costs in the real downstream costs of expensive tests and specialists.  That’s right, “you have drugs, surgery, imaging, or us”.  A simple analysis of the data will show that after six months of implementing this massive fee reduction that these downstream costs will increase-ultimately forcing increased costs to your customers-employers.

-while PT’s might be coded with “peace corps genes”, we are highly educated patient advocates and won’t sit still while your shortsighted actions take place-and neither will your customers.  In the days of social media and word of mouth marketing, Blue Cross of California might just get the Tiger Woods treatment in the press.

Then tell him Happy Holidays and expect to hear more from us in 2010.

larry@physicaltherapist.com

Winners of the EIM 2nd Annual Elevator Pitch Competition!

The winners of EIM’s 2^nd Annual Elevator Pitch Competition are….

·         1^st: Chris Robl- http://www.youtube.com/watch?v=KiEDB8V3zkk

·         2^nd : Cori Cameron- http://www.youtube.com/watch?v=-lZCLA_YQkA

·         3^rd : BJ Lehecka- http://www.youtube.com/watch?v=cMgRzAaZzW8

 

Thank you to all who submitted entries in the competition!

Executive Management Program trip to Zappos. Congratulations to Graduates!

EIM would like to congratulate the first class of the Executive Management Program which concluded this past weekend with our last on-site intensive in Las Vegas.  Several members of the class also received their tDPT having completed additional courses outside of the year long 16 credit executive management curriculum.

The highlights of the last weekend intensive were the presentation of the capstone project- business plans by the 5 teams who have spent this past year together collaborating and completing academic courses in strategy, finance, leadership, HR, marketing, PR, technology, business development, and legal issues.  All participants are in private physical therapy practice-a requirement-and they will continue be able to rely on each other via a sustained private community within EIM’s platform.

The other major highlight of the weekend was the surprise field trip and private tour of the insides of Zappos-a service company that just happens to sell shoes.  A number of significant lessons about customer service, culture, marketing, and engaged workplace can certainly be applied to physical therapy clinics.

Super job group!  Thanks for your outstanding participation and your commitment to private practice physical therapy.

Larry@physicaltherapist.com

As The Older Adult Population Grows, Are Physical Therapists Ready?

A large part of what we do as physical therapists is design programs to fit the individual needs of a patient.  I am very sure a lot of thought is put into the design of the program to be implemented to improve the function of the older adult we are treating.  I am also willing to bet that 75% or more of the time some type of strengthening exercise is included in the individualized program.  I assume this because muscle weakness is a normal part of the aging process.  The rate of strength loss occurs at about 1-5% annually after the age of 30 (Lindel, 1997).

I wonder... how much thought is put into the strengthening exercises?  How do physical therapists determine the intensity of the strengthening activity?  Do physical therapists rely on the results of manual muscle testing?  If the patient has a strength grade greater than fair, how does a physical therapist determine the workload for strengthening?  What do physical therapists think when a muscle grade of 5/5 is found during muscle testing?  Does a 5/5 muscle grade really mean the patient will perform "within functional limits?"  Did you know that the leg strength required to rise from a chair without using the upper extremities is about 40-47% of a person's body weight (Eriksrud & Bohannon, 2003)?

If you have a habit of strapping on a 2# ankle cuff weight on an older patient and then asking for however many repetitions of a knee extension movement pattern, ask yourself why?  Before you begin any strengthening activity, really try to perform a baseline assessment.  If your older patients are not performing exercises at 60% or higher of a 1 repetition maximum, ask your self why.  This is the intensity required to improve strength and function.  Sure, there are definite times when you don't want the patient even near the 60% or higher intensity level - like when they are learning the movement pattern (i.e. learning to control the movement, the speed of the movement, and the direction of the movement).  It probably doesn't take more than a couple of sessions for the control and correct movement patterns to happen.  Once the pattern is performed correctly and safely, it is time to increase the resistance of the activity.

Dale Avers, PT and Marybeth Brown, PT collaborated and wrote a White Paper on Strength Training for the Older Adult.

Are you demonstrating ageism?  Do you believe older adults are frail and will not respond to strengthening activities?  Do you fear they will injure themselves if exercising at 60% of 1 repetition maximum?

photo by KayVee.INC via Flickr

~Selena

Rational Irrationality and Value Based Reimbursement

I “tagged” the following under “evidence of rational irrationality”:

-The U.S. Preventive Services Task Force, a government appointed entity presented in its new guidelines that women need not get regular mammograms until they’re 50 and older and that those specific self-exam instructions are no longer recommended.  However, for reasons clearly based on emotions, the US Senate voted to not accept these recommendations.  Does this mean that every potential policy backed with “clinical effectiveness research” will be either individually voted on or put up for endorsement by the Senate?  Isn’t it a little odd that they would even vote on such a thing?  While we can always point out the case of the woman under 50 who was saved by a mammogram, we can also likely point to cases where radiation and perhaps unnecessary surgery was done in by a mammogram.  While EBP principles clearly show patient values as part of the equation, a “preventive” policy doesn’t mean that a mammogram can’t be done for those under 50–just means that it’s not recommended. What’s to stop the Senate from voting on changing the recommendation to 20 years old?  For those that responded to my tweet about this I can only assure you that I don’t know a single person whose life hasn’t been impacted by cancer so my point on this issue not meant to be insensitive in that regard.

-The Republicans voted against cuts in home health care because they claimed it would hurt a lot of patients that need it. Their votes didn’t help as democrats defended and upheld them in an attempt to keep the cost of healthcare reform under 1 Trillion dollars. I would like either party to explain to me how you are going to expand benefits and expand beneficiaries and save money in the budget (something that White House Budget chief Peter Orszag apparently is starting to echo as well) or how this will lower costs of health insurance from employers which both the CBO and HHS secretary Kathleen Sebelius contend in their analysis.

Fortunately, my work week ended listening to a compelling presentation on value based reimbursement and episodic care from somebody who represents a payor perspective and experience in physical therapy claims.

Payors don’t really understand our outcomes instruments nor should they.  If we can demonstrate that a patient’s care stayed “on protocol” this would provide an adequate proxy for outcomes.  The burden for continuous self-improvement and evaluation for staying “on protocol” should fall to the provider who must maintain systems for assuring this “loop” which would further require implementation of evidence based practice and integration of research into practice.  I can personally only think of a handful of protocols that can truly meet this outcome “proxy” but they are at least hi cost drivers in the system-notably acute low back pain and fall/balance.  We might even see a “case” copay versus a per visit which would definitely place some added responsibility on the patient as they would naturally react to “under” treatment and “over” treatment which are the current repercussions of capitation (or low per visit/case rates) and fee for service environments.

Definitely, some interesting stuff.

Thoughts?

larry@physicaltherapist.com