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What You Might Not Know Joe

File this post under “why there is a blog focused on evidence based practice in physical therapy”.

One of my favorite healthcare bloggers is Joe Paduda and his Managed Care Matters.  I find many of his worker’s comp particular posts informative.  A few weeks ago, in response to the NY Times Gina Kolata article, Joe responded with a “How many dollars are wasted on physical therapy?” post.

In subsequent comments and updates (particularly in response to a very detailed comment on his blog), Joe provided further clarity and data to his post (at bottom of page).  It would be very hard to disagree with some of his more significant points-PT is in fact a “black whole” in worker’s comp and there are far too many providers that take advantage of worker’s comp first dollar coverage and see patients for hundreds of visits. 

 My advice Joe would be to dig deeper into the data and marketplace and you will find some interesting things including:

Over-utilization:

 

We agree that physical therapy is often over-utilized.  Which is really quite amazing when you consider that NO physical therapy is rendered in workers’ compensation without a physician referral and authorization by the payer.  So how is it possible that PT would be so abused? 

 

Answer: PT has become a “money machine” for the very physicians who are supposed to be the system “gate keepers”.

 

As “gatekeepers” physicians enjoy unfettered control of the physical therapy market, having the exclusive authority to prescribe the service while at the same time owning the clinics to which they refer. 

By design this conflict of interest is rampant in comp and growing exponentially. 

 

And what’s so puzzling  is that in spite of the evidence that this conflict of interest results in lower quality of care and is a major cost driver, neither the regulators nor payers have shown any initiative in dealing with it. 

 

-Practice Guidelines:

You are right about the scarcity of published guidelines for  PT  -  what to do and for how many visits.  However, there are currently significant efforts underway to establish PT practice guidelines for the most common conditions encountered by physical therapists. Although these guidelines are not specific to work comp, the recommendations certainly apply to the large majority of work comp cases and will help inform best practice for both work comp cases as well as the care of patients from other payer sources. Bear in mind that although practice guidelines are certainly a start, they certainly no panacea for the problems in work comp given their inability to effect behavioral changes consistent with guideline recommendations unless other reforms are brought to bear (i.e. payment incentives to simply do more procedures rather than generate an optimal outcome). Also, before we get too critical on the lack of guidelines for PT, where are the guidelines for orthopedic surgeons and pain docs?

One area where we have quite adequate guidelines to inform optimal PT management is low back pain, which as we know is one of the highest cost drivers in the entire health care universe.  The recent ACP-APS guidelines on the non-surgical management of low back pain is a very good example of this.  Again, the problem is not so much the lack of guidelines as it is the abundance of perverse payment incentives and conflicts of interest (ie, physician ownership of PT) that encourage everything but adherence to best practice according to practice guidelines. There are in fact providers following the best EBP guidelines and producing extraordinary outcomes but due to self-referral patterns and the fragmented work comp system, they are often times simply cut out of the system.   Or, to make matters even more egregious, these same independent, outcome-driven providers are actually “punished” by a system that rewards doing more procedures rather than rendering good care.

-While you acknowledge the potential conflict of interest by citing Medrisk’s “most thorough published” (an arguable point by the way and one in which I think you are misguided) Expert Clinical Benchmarks, I would argue that they (Medrisk) contribute to the problem. Take a straw vote and you will find that their adversarial “just say no” relationship with providers has caused a significant number of the top quality providers to opt out of plans in which Medrisk is involved.

“Managing” care by simply denying it may be good for MedRisk’s bottom line but is simply a capricious exercise in rationing care, which survives only because there are no clinical outcome performance metrics monitoring the consequences.

Too little care is probably more problematic than too much due to the significant downstream costs of imaging, drugs, and surgery-particularly in LBP.

Joe, you’ve posted before on the topic of how these PPOs and TPAs have turned the process into a profit center.   At the same time they pay providers below their costs, often time 50%  below Medicare rates. 

We believe the system has been bastardized to the extent that costs are needlessly out of control while  injured workers are being shortchanged and denied access to the very care they need for early return to work.

If professional football players were covered under workers’ compensation rules the NFL wouldn’t be able to field a single team. 

Joe, how about a post in Managed Care Matters about the potential of significant savings of work comp dollars by disallowing conflict of interest referral for profit situations, contracting only with independent PT providers who “show your their guidelines, how they comply with them, and their 3^rd party produced outcomes”. 

Thoughts?

larry@physicaltherapist.com, john@texpts.com, rick@physicaltherapist.com

 

 

Process beats Outcome in Physical Therapy

The current tally of officially recognized 'process' vs. 'outcome' measures in health care from the National Quality Measures Clearinghouse (NQMC) favors 'Process' over 'Outcome' by 997 to 368. If physical therapists define quality by 'how' we deliver care over 'how much better' our patients get - then our patients are in trouble.

click image to view larger size

Why is this important? Outcomes-based care is where the United States health care system is going. Physical therapists can be leaders in this transition. The adoption of outcome measurement by our profession will the the 'speedometer' by which that transition is gauged and will ultimately decide the winner. Unfortunately, the adoption of evidence-based outcomes tools is slowed by the burden of 'process-based' measures in physical therapists' clinics. A partial list of some 'un-official' process measures in physical therapy:

• Therapy cap exceptions process (-kx modifier)
• ‘Skilled therapy’10th visit progress note
• 90-day certification of the plan of care
• Physician signature of the plan of care
• AMA definition of physical therapy practice (via 15-min CPT codes)
• Automatic CPT coding edits 1-on-1 procedure codes
• time-in & time-out
• Medicare Minimal Documentation Requirements
• ‘8-min. rule’
• Discharge from physical therapy

These process measures, that dictate 'how' physical therapy is provided, all but eliminate the time, energy and money required for investments in true quality. Where does all the time and money go? Physical therapists nationwide (~177,000), especially those working in outpatient therapy clinics (~65,000) are burdened by excessive documentation of uncertain value - the primary reason for documentation seems to be to protect ourselves from Medicare audits.

Witness this description of the 'process-oriented' note that is supposed to accompany the billing of one, single code for Therapeutic Exercise (CPT 97110):

"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait"

This description was made by Medicare auditor and former private practice physical therapist Steve Levine, DPT in a February 3rd, 2010 webinar called "Will Your Documentation Trigger an Audit?" Dr. Levine's recommendation to over 400 members of the webinar cast a chilling pall over the prospects for improvements in the rate of physical therapists' adoption of outcome measures in the short-run. The very last question in the webinar was posed by a physical therapist clearly non-nonplussed by the idea that every 1-on-1 procedure code need to be accompanied by this lengthy, narrative description. Dr. Levine did not relent, implying that we need to spend as much time writing justifications for our care as we spend providing our care. Some Process Measures are not statutorily based Keep in mind that Dr. Levine's recommendations are just that - recommendations.

The Medicare Minimal Documentation requirements do not specifically require this level of narrative: "...a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task... Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition... ...Documentation should establish through objective measurements that the patient is making progress toward goals... ...It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus." (Transmittal 88, page 25-26)

I could have written Dr. Levine's narrative description in 1992 - the year I graduated from PT school. Why should I write it now, in 2010? Are we all crooks? Is physical therapy still practiced the way they taught me then? I don't think so - today we have evidence-based physical therapy (the term was only invented in 1991).

Surely the profession could come to a consensus on what constitutes 'skilled physical therapy' that incorporated the best, up-to-date evidence on screening for pathology, treatment based classification and interventions supported by grade 'A' or 'B' trials rather than case studies or anecdote. Right now we are abdicating our profession to self-serving, ex-clinicians with out-of-date treatment paradigms. Why couldn't Federally mandated evidence-based outcome measures supercede process-based time-wasters? Let's bring Medicare audits (and Medicare auditors) into the 21st century. Let's reverse the score: 997 to 368 Outcomes over Process.

Tim Richardson, PT www.PhysicalTherapyDiagnosis.com

EIM and Sports Medicine: The EIM Emergency Response Course

EIM will be leading the way in evidence-based Sports Medicine and will launch this effort by offering the Emergency Response Course, taught by Dr. Teresa Schuemann. The course is a pre-requisite for our June 2010 Sports Medicine Residency Cohort (yes, you read correctly....Sports Medicine Residency,  more details will be coming soon from Dr. Schuemann, who is serving as Program Director,  but put it on your calendars: the EIM Sports Medicine Residency will roll-out its first cohort this June!) However, we are opening enrollment to the EIM Emergency Response Course to all interested therapists.

This course integrates the objectives set forth by the American Red Cross and the Department of Transportation for Emergency Response and is designed specifically for the physical therapist seeking to provide athletic venue coverage and respond appropriately to acute injury.  The class includes instruction and discussion of assessment, management and prevention of cardio-respiratory emergencies, musculoskeletal injury, environmental injuries and medical emergencies such as shock or diabetic reactions, brain injury and spinal injury.    An intensive laboratory weekend is included. This course fulfills the requirements for a physical therapist to be eligible for Sports Physical Therapy Residency Programs and submission of application for the ABPTS- SCS examination.   

Successful completion of both written and practical examinations will be required for this course.  The final practical examination will include successful completion of the following: bleeding control and shock management, trauma victim assessment and management, airway insertion and suction, management of injuries to soft tissue and skeletal structures and management of head, neck and back injuries.  Following successful completion of the course, the participant will be awarded a First Responder Certification (good for 3 years) and a CPR/AED usage for the Professional Rescuer Certification (good for 2 years).

 We look forward to taking sports medicine to the next level in 2010 -- and it all starts with this course!

Thanks!  Rob Wainner

Yes, Gina you can tell if your physical therapist is "voodoo less"

And Dr. Irrgang’s litmus test is just a start.

In what might be the most emailed article to hit the social networks of physical therapy comes this gem from the NY Times entitled Treat Me, but No Tricks Please by Gina Kolata.  I wish more consumers were as inquisitive as Ms. Kolata as it would be a boon to PT practices that train, practice, and insist on evidence based practice.  I only hope that Ms. Kolata likewise inquires her physicians on treatment interventions for other conditions-am confident that it would highlight even more the significant lack of evidence in medicine generally.

The article raises great points-evidence, cost of PT, unproven interventions, stretching, research and apparently the easy referrals generated by MD’s in New York for physical therapy (side question for Gina, do these docs refer to their own clinic or any clinic?).

For purposes of narrowing the focus to make a point, I am only going to concern myself with the last issue raised:

“with all that voodoo physical therapy out there, though, how can you tell if what you are getting is helping or useless?”

Dr. Irrgang essentially suggests that you have to be inquisitive and find a PT that can explain the benefits and risks of various treatment options and who can defend evidence to support their treatment.  I think this is a good start. 

I would add the following 4 questions:

*Can you provide evidence to support treatment in the most common PT diagnoses-low back, cervical, upper extremity, lower extremity, and therapeutic exercise generally.

*Are you board certified in your specialty area, residency or manual therapy fellowship trained?

* Can you supply reports from external organizations that indicate your patient satisfaction/loyalty or clinical outcomes?

* How does your organization provide PT’s on-going training and feedback to ensure consistency and decreased variation of treatment interventions across the most common conditions? 

My recommendation to Gina or any other inquisitive consumer is if the answer to any of the questions other than the second one is “no”, move on until you find a “voodoo less” therapist.

I look forward to the thoughts and comments on this issue and the NY Times article.

larry@physicaltherapist.com

 

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!

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

Spending Money to Save Money-Innovation vs. Marketing

I recently had a sandwich prepared with white wheat bread.  It is essentially whole wheat bread “disguised” as traditional white bread.  The intent I guess is to provide for me a healthier option without me really knowing it.  Not sure this qualifies as innovation or marketing.

The same is true of for IBM’s decision as reported in Oct 29th WSJ article regarding dropping co-pays for primary care visits.  IBM is one of largest employers in the US and spends about $1.3 Billion on healthcare.  Because they are self-insured, they carefully watch every dollar spent in the medical system.  It is their belief that they can save significant money by incentivizing folks to use primary care physicians by eliminating co-pays so they can get earlier diagnoses that can save more expensive visits to ER’s and specialists.  I will let you decide whether this is innovation or marketing.

Contrast this to the incentive system in Massachusetts “global payment” system which creates tremendous incentives to render as little care as possible.  If your care costs less than an annual allotment, then they (medical providers or a hospital) keep the unused amount.  While the pendulum on too much care in the US is undeniable, its compete counter of too little is equally as bad.

My post last week on “bundling” creates a financial incentive for a patient to choose a provider within a set system-the patient essentially gets a cash rebate under that demonstration project (side note:  this worked real well in the auto industry).

I seriously doubt IBM will save money under their initiative since primary care docs are in a shortage and patients will simply get frustrated and pay the co-pay to see a specialist. All IBM needs to do is look at Massachusetts primary care waiting in their system which is 2–3x national average!However, I do think that all of these marketing tactics can be replaced by real innovation- which would take into account best current evidence, utilization data analysis, and some element of financial incentives to drive patient choices.

Here is a start of a list for PT that tries to couple this concept:

1. Pay patients $20 rebate for seeing a PT for musculoskeletal cervical or lumbar pain.  They first follow a simple online or iphone/blackberry app that largely eliminates the major red flags that would guide them to a more appropriate provider.  The $20 would be well spent.  Savings on imaging and drugs would be astronomical.

2. Any service done thru physician self-referral has an additional $200 co-pay.  Routine lab and X-ray would not be included.

3. Patients have zero co-pay if they pro-actively pick their personal family physical therapist who is board certified or resident trained and who actively participates in 3^rd party outcomes.  Their personal PT also agrees to answer emails/texts/phone calls about routine musculoskeletal complaints and provide a free fall balance screen once the patient turns 60.

Combining evidence and incentives vs. marketing. That just might get us to some real answers.

Thoughts?

larry@physicaltherapist.com

Wait & See, Neck Collar Or Physical Therapy for Cervical Radiculopathy?

What to do for neck and arm pain that started within the last 30 days?  Drum roll... which will it be the a) just wait and see what happens, b) the semi-hard collar (Cerviflex S, Bauerfeind)  which has 6 sizes to snuggly fit necks of all sizes, or c) physical therapy?  The winner is.... the Cerviflex S semi-hard collar!

In this century of effectiveness and effectiveness studies.... What a spectacular day for people who have cervical radiculopathy - just strap on a snug fitting semi-soft neck collar and life will be fabulous within 6 weeks!

I was fearful of these types of studies because the devil is in the details and as a whole, we are lazy.  Which is more realistic?  Read an abstract and believe the conclusion OR read the full study and reflect and think?  I'm betting most will read the abstract and believe the conclusion.

I liked that the subjects seemed to be a homogeneous group.  I like the fact that the same collar was consistently used.  I don't like not knowing psychosocial factors.  I really don't like the description of what physical therapy intervention was provided.  "Physiotherapy with a focus on mobilising and stabilising the cervical spine was given twice a week for six weeks, by certified physiotherapists who participated in the study. The standardised sessions were "hands off" and consisted of graded activity exercises to strengthen the superficial and deep neck muscles."  

Current literature indicates that manual intervention and exercise are key components for a successful outcome with various types of patient complaints.  Standardized sessions that are hands off do not meet the requirements of evidence.  The design of the study capturing the interventions provided by physical therapists really wasn't up to speed on the existing evidence on how physical therapists treat patients with cervical radiculopathy. 

It's a sad, sad day when the physical therapist involved in the design of the physical therapy intervention wing of a study didn't incorporate evidence into the treatment protocol.  I really have a problem with the design of the standardized physical therapy sessions!  Where was the evidence for the protocol?

So, the big question... which payer will see the abstract... which payer will deny payment for physical therapy services because physical therapy services are not cost effective and a neck collar will "effectively" take care of the patient's cervical radiculopathy?

~Selena

2010 International Private Practice Business Summit!!

Larry Benz at the 2010 International Private Practice Business Summit

 

Hello!

I would like to personally invite you to the 2010 International Private Practice Business Summit on January 22-24, 2010.  The Summit is a 3-day business meeting for private physical therapy practice owners. There will be more than a dozen experts presenting on topics related to the business of physical therapy and strategies for creating high performing and prosperous world-class clinics.  This Summit will motivate, inspire and teach everything you need to know to transform your clinic into a top-notch, competitive, enjoyable business. 

 

I will be presenting “Clinical Excellence Begins with World Class Customer Service”  on January 22^nd.  While physical therapy clinics are stressing their clinical expertise, practices with unprecedented focus on the customer experience and service excellence are gaining market share, “buzz”, and loyal repeat patients trumpeting their competition.  I will focus on the ultimate outcome of a physical therapy experience-an emotionally engaged, enthusiastic ambassador who has been impacted for life from treatment at your physical therapy clinic.   This session will give you the tools to deliver and sustain “the best” customer service experience for your patients.

 

Registration opens today, October 28.  If you register prior to November 19 you will receive an early decision maker discount.  Click here to register.  

 

Hope to see you there!

Larry