MyPhysicalTherapySpace.com - A part of the 1T - the "One Thing" you need for PT practice.

Growing Technology in the World of Physical Therapy

The American Physical Therapy Association Combined Section Meeting will be here before we know it.  I've been checking out the programming and figured I'd begin to share sessions that spark an interest for me.  Granted, our profession spans multiple types of settings and various types of patients.  I realize what may spark an interest may not necessarily be conducive for attending because we don't practice in that particular realm of physical therapy.

When you think about our bodies and how we learn how to do things, it makes such practical sense to basically have people with substantial movement dysfunctions be able to learn from their movement mistakes.  Personally, I have never exactly understood how people with neurological deficits really learn efficient movement patterns when we as professionals focus on protecting them from falls or adverse events.

The ZeroG dynamic body weight support system looks cool!  I remember years ago telling a patient who had a stroke that if I could string her up from the ceiling, we could have a lot of fun, a few laughs and she could really learn how to improve her balance.  What is fabulous about this session is the fact that research is being conducted on the benefit of this particular weight support system for people who have had an acute stroke.

If you are interested in finding out more about this available technology (and I'd assume some pre-published research results), Diane Nichols has a session on Thursday, February 18, from 2:30-4:30 pm.

photo snagged from CABRR site (I assume they won't mind?)

~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

Friday Private Practice Physical Musings

On wayto PPS National Meeting for a presentation tomorrow entitled Charity Good For Business? I am gong to have participants text or twitter me questions and feedback during the presentation.  We shall see how it goes.

Online access courtesy of Delta airlines for $12.95.  Data shows that few people actually pay this-similar to the phones that used to be in airplanes. My guess is airlines will all go this route anyway-similar to PT practices that get a biodex, BTE, or any capital intensive piece of equipment just because their competor has obtained it.

Enjoyed reading this article in NEJM about controlling US Healthcare spending.  They looked at 12 policy options and the ability (or lack thereof) in decreasing cost.  Other than bundled payment, the savings are marginal at best, are not real likely to occur, and would result in a loss of income to someone along the chain.  We already have addressed why bundling won’t work. Looks like we are headed to more of the same from my standpoint.

Was reading in WSJ about a proposed plan to put medicare tax on capital gains for healthcare reform.  This is very confusing to me as I thought healthcare reform and any potential publich options was not about medicare.  Perhaps they will rename it healthcare reform tax. Maybe they are just running out of names for taxes.

Read an equally confusing CMS release about shelving Medical Home Demonstration project.  This is one that I substantially agree with.  Perhaps CMS is reading this blog and my contention about them from last April?

Cheers!

Larry@physicaltherapist.com

Halloween and the Bundling Flaw

Larry gave me the most excellent idea.  Bundling the Cost of Care got me thinking about the future.

Last night was my initiation as a physical therapist gone negotiator!  I was 100% successful in acquiring THE largest pieces of chocolate candy (or whatever choice I wanted) out of the bucket!  In some cases, the whole bucket of candy was just handed to me!  (I was polite every time and smiled and said, "thank you.")

I am so ready to be at the service of any physical therapist that has to negotiate with some large hospital system for the payment of physical therapy services provided by an independent physical therapist.  Trust me, as your negotiator, I know how to walk quietly and carry a big stick.  Your company will survive this change; you and your family will survive this change.  I know you have to put food on the table and eat.  Call me and make my day... I am so ready to negotiate for you!

Physical therapists in independent practice really can't negotiate AND treat patients.  Consumers really should have quick access to physical therapists no matter where they practice; consumers should have the freedom to choose their physical therapist.  Seriously now... Larry didn't get any responses.  My humor won't solve the issue.  Really though, will the next growing field in the future be physical therapist gone negotiator? 

photo by dunechaser via Flick

~Selena

The Results of One Court Case Will Affect the Nation

Is an orthopaedic surgeon a "qualified health care provider" with regard to providing physical therapy services?

According to the Kentucky Supreme Court, yes, an orthopaedic surgeon can provide physical therapy services and is a qualified health care provider. What can I say? Over the last 6 years, the case went through the whole darn court system and a final ruling occurred in the Kentucky Supreme Court. The result... since section (1) proviso allows orthopaedic surgeons the authorization to provide physical therapy services, but since section (3) disallows the orthopaedic surgeon from referring to the services as physical therapy either directly or indirectly - an "absurd" situation is created. Apparently, the General Assembly wanted the statute to be considered as a whole and for all pieces within the statute to be relevant. The General Assembly would not want an absurd statute.  It all comes down to it being absurd that an orthopaedic surgeon can't offer and bill for physical therapy services provided by an athletic trainer using CPT 97001 and 97002.

Personally, I find it not only absurd but also illogical that an orthopaedic surgeon would be allowed to provide physical therapy services without a physical therapist providing services.

If we put some practicality into the situation... first of all, an orthopaedic surgeon is not in the clinic every day of the week.  The "surgeon" will have 1 or 2 days (or more) per week in an operating room, right?  So, when the surgeon is operating, the surgeon really can't be supervising any physical therapy services that might be concurrently provided within the surgeon's clinic right?  We'll forget about that reality for a minute.  When the surgeon IS in the clinic, what is the surgeon doing?  If we guesstimate the surgeon has an 8 hour working day, then that means the surgeon has basically 480 minutes.  Of that 480 minutes, the surgeon will probably have 20% downtime - waiting for radiographs or MRI results or conversing with other colleagues or documenting... that leaves 364 patient contact minutes.  Approximating an average of 10 minutes of surgeon-to-patient contact, a full day would be approximately 36.4 patients.  In that full day of surgeon-to-patient contact, does it seem reasonable that a surgeon would have the time to adequately address and supervise the provision of physical therapy services being provided by an athletic trainer?

Until third party payers eliminate referral for profit situations, the Kentucky Supreme Court opinion just may create ripples across the nation substantiating the legal right for physicians to provide physical therapy services.  Until consumers care enough to compare before they seek a physical therapist for their condition, the situation won't change.

Is it possible for physical therapists to create a viral message?  Physical therapy isn't physical therapy without a physical therapist. Put the PT in physical therapy. 

What are your thoughts?

~Selena

Medical Necessity... To Fix A Problem There Cannot Be Two Standards

Health Care Reform... 21.5% reduction in payments to providers... possible shifting of reimbursement to favor primary care physicians... possible reducing payments to physical therapists to increase payments to cardiologists and oncologists. 

It seems to me to really resolve any problem there are always various considerations.  In the case of health care reform... there are at least 3 entities to consider.  1)  Medicare - its processes:  the inefficiencies, strengths and weaknesses  2)  Providers -  their processes:  how clinical decisions are made, the risk/benefit of the decisions and 3) Patients - their behaviors:  when they seek services, their responsibility in taking care of themselves, when they make poor choices.

I am so ready for a primal scream when I see something like the above and then read the details.  The government can't have it both ways... their audits in clinics capturing money paid inappropriately due to lack of "medical necessity" basically based on review of records yet the allowance of $60 billion in fraud to people who easily scam Medicare!  Medicare is paying for that fraud annually (of course, these are just the ones who got caught)!  In all honesty, providers should not take such a hit in reimbursement yet.  Medicare should have its own work cut out to clean house and ensure someone really needs an electric wheelchair or an electric prosthesis.  Amazing to hear Medicare will easily pay for 2 lower extremity prostheses and an electric upper extremity prosthesis on the SAME person!  Now come on, how many people 65 and older do you know who are THAT bionic?? 

I have no clue how powered mobility devices are billed.  I do know if a patient received any kind of prosthesis concurrently there would be claims sent for physical therapy and maybe occupational therapy.  I would think a darn computer system could process durable medical equipment claims for defined durable medical equipment items 20-30 days after receiving the claim and only pay if inpatient services or outpatient physical therapy services were provided within the same time frame.  I'd highly doubt anyone receiving a prosthesis would know how to function and be safe without some level of education and training.  Even if the prosthesis was a replacement, Medicare can just make a rule that rehabilitation services are required. 

If 10-12% of claims are for physical therapy services, does it seem strange to anyone else that OIG will be focusing on outpatient physical therapy services provided by independent physical therapists?  I highly doubt that physical therapists in independent practice are exploiting the Medicare system intentionally or unintentionally at the magnitude the guy in the video was.

~Selena

A Feasibility Study

Direct access for physical therapists isn't new.  Direct access has been around since 1957.  Can the the decision-makers within 44 states be wrong?   Safety... I would think that could be answered by analyzing claims data.  The only source I am aware of is by CNA. 

I am supposed to be happy about an amendment added to "America's Healthy Future Act" which will allow someone to research direct access for physical therapy services for beneficiaries in rural areas.

Am I allowed to ask... where's the logic?  First of all, research costs money.  Is there money available to adequately research the issue?  Secondly, there is a shortage of primary care physicians.  Researching takes time.  Won't timely access to care continue to be compromised?  Thirdly, why only beneficiaries in rural areas?  And fourth, can 10-15 minute physician visits lead to a reduction in falls, vertebral fractures and joint replacements?

In instances like this, I tend to think, just do it.... direct access to physical therapy services for all Medicare beneficiaries.  Really, what's the worst case scenario?  And with the worst case scenario, what's the potential likelihood or probability of the worst case scenario occurring?  What's the potential likelihood or probability for good to occur?  What really stops direct access from occurring - fear or profit?  Seems as though some change is definitely needed... doing the same old, same old isn't going to change the outcomes.

~Selena

Twitter and Tweets and Twits

You read correctly... twits.

Curiosity killed the cat.  I was curious about Twitter.  I've been reading a lot of tweets about "back pain."  It's very easy to search for terms with TweetDeck.  Social media and all the venues for communication are fabulous, yes.  There are twits out there though... the freedom of speech is great, but what if liberties are being taken and what is being spewed is just crap?  Oh, and crap gets retweeted and retweeted.  The more it gets retweeted the more truthful it must be, right?

Let's take today for the last few hours: 

Arthritis Back Pain Management and What Causes Back Pain:  Nice start with the video but then progressively worsens to increase fear level AND plants the seed multiple diagnostic tests are needed.  The written portion focuses on tylenol for treatment.

Chronic back pain "sufferers" need to plan on a massage every 3-4 weeks - a solid massage therapy wellness plan. 

The "Back Pain Myths" Slideshow has a great beginning until... until slide 9.   " The American College of Physicians and American Pain Society guidelines for treatment of lower back pain recommend that patients and doctors consider spinal manipulation -- either by a chiropractor or a massage therapist -- for patients with back pain."  Ooops...

Back to the Basics, of course, suggests many diagnostic tests and to see a doctor.

I read zero tweets from physical therapists about back pain.  We treat this every day - day in and day out.  It'd be nice if there were physical therapists out tweeting the twits. 

To end on a positive note:  Here is something noteworthy from Arthritis News:  There is now a new diagnostic rule for vertebral fracture:  female gender, age > 70 years, significant trauma and prolonged use of corticosteroids.  The likelihood ratio increases, of course, the more factors present.  The published findings can be found in Arthritis and Rheumatism.  Arthritis News shared this article.

Does anyone else believe it might be a good idea to join the social media and drown the twits?

~Selena

photo by Paul Denton Crocker via Flickr

Deaths Due to Lack of Insurance

The world probably would be a better place if everyone had health care insurance.  I say *probably* because it really does seem like the right thing - a human thing - a caring thing. 

A recent study attributes 45,000 deaths a year  due to lack of insurance.  The population considered were 64 years of age and younger.

If I am allowed to extrapolate a little bit using some current data for uninsured, that means that 46.3 million uninsured run a risk of dying because they don't have health insurance.  So, even though the 1 death in every 12 minutes computation sounds horrible, mathematically the occurrence is something like .0972%.

Now the flip side... life isn't a fairy tale.  Just because one has medical health insurance does not mean death won't occur.  There happen to be reports on in-hospital medical deaths.  (And this considers only the 65+ age group!)  These reports have led to the 100,000 Lives Campaign and then the 5 Million Lives Campaign.  Medical mistakes could potentially be rated within the top 5 or top 10 causes of death.  Depending on what research you want to read, Starfield estimates iatrogenic causes for about 225,000 deaths.  Mathematically, this comes to about .0882%.

Take another slightly different spin:
2.5 million deaths/year
45,000 deaths/year due to lack of insurance
225,000 deaths/year due to iatrogenic causes

If we do the math, we have WAY more problems in our health care system than uninsured, don't you think?

It's almost as though we make a choice.  Why do we choose the fairy tale choice?

~Selena

photo by chasingEchos via Flickr

Physical Therapists and Moving Forward

What's beer got to do with it?  A lot. 

Michigan Brewing Company does it right.  Greater success and growth happens the more you rely or network with others.  This company is an excellent example of how creating beer can be so much more than creating beer.  This company has embedded itself in the community and win-win relationships have occurred.  At the same time, this company also forged a relationship with an individual who was instrumental in changing Michigan law.  The change is better from a business perspective for this company and others like it.

As physical therapists "Move Forward," who have we networked with?  Who do we have win-win relationships with?  Are we moving forward alone in hopes for success?  Should we have fear in creating a foundation of moving forward WITH others with similar agendas?

What about nurse practitioners...  here is an opportunity for some mutual networking where together a better solution occurs:

During their “Raise the Voice” campaign, the American Academy of Nursing (AAN) stated that the role of community-based nurses should be reexamined during the healthcare reform debate, given the growing shortage of primary care physicians across the country. According to Tine Hansen-Turton, CEO of the National Nursing Centers Consortium (Philadelphia), “Now may be the time to "think outside the box" and increase reliance on non-physician groups and physician assistants and expand to non-traditional settings such as nurse-managed health centers and convenient care clinics.” HealthLeaders Media reports that 85,000 nurse practitioners – of about 145,000 – are currently providing primary care and that NPs are one of the fastest growing groups of primary care professionals nationwide. Donna Shalala, former HHS Secretary and a speaker for AAN's “Raise the Voice” campaign, noted that more recognition is needed for the role that NPs play in expanding access and providing primary care. She stated that nurses “need a seat at the table” during healthcare reform debates and additional federal funding for nurse-managed health centers. (Simmons, Janice. Group Says Community-Based Nursing Model Could Boost Primary Care Coverage, HealthLeaders Media, May 11, 2009)

We are an "outside the box" potential and we are a non-physician group.  Wouldn't they love to have us on board WITH them?  What are your thoughts?

Cheers!

~Selena