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Office Memo regarding MedPAC Report

Who:  MedPAC':

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

When:  June 2010

What:  Report to Congress:  Aligning Incentives in Medicare



10 Top Quotes

1. "Moreover, there is evidence that some diagnostic imaging and physical therapy services ordered by physicians are not clinically appropriate."

2.  "there is evidence that physician investment in ancillary services leads to higher volume through greater overall capacity and financial incentives for physicians to order additional services. In addition, there are concerns that physician ownership could skew clinical decisions."

 

3.  "we report that outpatient therapy (such as physical and occupational therapy) is rarely provided on the same day as a related office visit. In addition, half or fewer than half of imaging, clinical laboratory, and pathology services are performed on the same day as an office visit. The finding that many ancillary services are not usually provided during a patient’s office visit raises questions about one of the key rationales for the IOAS exception—that it enables physicians to provide ancillary services during a patient’s visit."

4.  "The Commission does not make any recommendations in Chapter 8, but it does explore several options in more detail:

• excluding therapeutic services such as physical therapy and radiation therapy from the IOAS exception,"

 

5. "On the other hand, physician investment in ancillary services could lead to higher volume through greater overall capacity and financial incentives for physicians to order additional services. A study by Baker and colleagues estimated that each additional MRI scanner in a market is associated with 733 additional MRI scans among Medicare beneficiaries, and each additional computed tomography (CT) machine is associated with 2,224 additional CT scans (Baker et al. 2008). It is unclear whether the growth in scans is driven by changes in demand for medically necessary care or changes in the supply of machines. Several studies—including recent research conducted by the Commission—have found that physicians who furnish imaging services in their offices refer patients for more imaging than other for MRI or computed tomography (CT) scans engaged in a block lease or similar arrangement (Mitchell 2007)."

 

6.  "Researchers also found that physicians with a financial interest in physical therapy initiated therapy for patients with musculoskeletal injuries more frequently than other physicians and that physical therapy clinics with physician ownership provided more visits per patient than non-physician-owned clinics (Mitchell and Sass 1995, Swedlow et al. 1992)."

 

7.  "Questions have also been raised about the medical necessity of physical therapy services (Medicare Payment Advisory Commission 2006a). An Office of Inspector General (OIG) investigation estimated that 26 percent of physical therapy services billed by physicians that were provided during the first half of 2002 were not medically necessary (Office of Inspector General 2006).

8.  Outpatient therapy services are not generally associated with a related office visit. In 2008, only 3 percent of outpatient therapy services were provided on the same day as an office visit, 9 percent within 7 days after a visit, and 14 percent within 14 days after a visit (Figure 8-2). These results are not surprising; under Medicare’s coverage rules, a beneficiary does not need to receive an office visit with each outpatient therapy service. Instead, a physician must certify the initial plan of care within 30 days of the initial therapy service and must recertify the plan of care every 90 days (Centers for Medicare & Medicaid Services 2007b). In addition, patients tend to receive multiple sessions of therapy within an episode of care (Ciolek and Hwang 2004).

 

9.  Physician investment in therapeutic services may differ from investment in diagnostic services because of its potential to skew clinical decisions about the treatment of patients. For example, some have suggested that financial incentives may influence how cancer patients are treated. One study found that physicians who were paid more generously than the national average for chemotherapy drugs prescribed more costly chemotherapy regimens for certain types of cancer patients (Jacobson et al. 2006). In addition, therapeutic services are not typically ancillary to a patient’s office visit. Outpatient therapy and radiation therapy generally involve multiple sessions and are rarely initiated on the same day as an office visit.14

 

10. Concerns about excluding outpatient therapy and radiation therapy from the in-office ancillary services exception There may be concern that excluding outpatient therapy and radiation therapy from the IOAS exception would inconvenience patients by forcing them to receive care at hospitals. However, physical and occupational therapists can deliver therapy in private practices that are separate from physician groups. Patients can also receive therapy in ORFs, CORFs, and SNFs.

Why:  Overall, spending for outpatient therapy services paid under the physician fee schedule grew from $1.4 billion to $2.2 billion between 2003 and 2008. These figures exclude outpatient therapy provided in hospital outpatient departments, outpatient rehabilitation facilities (ORFs), comprehensive outpatient rehabilitation facilities (CORFs), and skilled nursing facilities (SNFs). The share of spending for therapy services that were provided incident to a physician’s service declined by nearly half between 2003 and 2008, from 30 percent to 16 percent. “Incident to” services are provided by therapists employed by a physician’s practice. Meanwhile, the share of payments for therapy services delivered by physical or occupational TPP, who bill Medicare independently, grew from 70 percent to 84 percent. Several factors help explain the growth of services provided by TPP:

• In 1999, CMS allowed licensed employee therapists to begin billing Medicare independently; previously, owners of therapy practices had to be on site and do all the billing for services furnished by employed therapists.

• Also in 1999, CMS eliminated payment disparities between settings for therapy services; as a result, many therapists changed their practice from an ORF to an independent practice to avoid the survey and certification requirements of institutional settings.

• CMS clarified in 2003 that therapists could be employees of physicians’ practices but still be considered in independent practice, which allowed physicians to employ therapists without being responsible for supervising their work (Medicare Payment Advisory Commission 2006a).

 

Top 5 implications:

1.  PT is not "ancillary".

2.  Physician owned PT/OT clinics can skew clinical decisions about the treatment of patients.

3.  Without POPTS clinics patients will have plenty of access to PT thru a number of channels, including private practice PT's.

4. PT patients referred by POPTS seldom get PT the same day (side note: there is an obvious reason ignored or unknown to MedPAC-most intermediaries won't pay for PT eval on the same day.  This alone supports the contention that it in office PT is purely financial).

5.  Need to track PTPP which is MD versus private practice.

What is needed:

1. End IOAS exception for outpatient physical and occupational therapy

2. Put pressure on OIG to designate physical therapy as a designated health service whereby POPTS docs would be obliged to:

     1.  Disclose to patients that they have a financial interest in the physical therapy clinic that they refer patients.

     2.  Provide alternatives to self referral including names and addresses of physical therapy clinics

     3.  Inform the patient that they are free to seek services elsewhere and if they do they will not be discriminated against.

3.  In the absence of #1 and #2, create an MD Amnesty Day where all POPTS fess up about their self referral interest in physical therapy and permanently use #2's 3 step process.  Fuel the Amnesty Day thru social media, national PR, and marches.

4. More research.  Studies in PT demonstrating overutilization by MD's are 15-18 years old.

Thoughts?

larry@physicaltherapist.com

This blog post is the product of my own conclusion.

 

National Physical Therapy News Month

The last several days there has been several news items impacting physical therapists:

-we had over a drop of 21% in Medicare with claims withheld and then another temporary fix thru Nov which resulted in a 2.2% increase

-Medpac  released a significant report telling us what we already know-physicians overutilize PT services when they are "in office ancillary".

-MD/PT partners in an email style that is a combination of Publisher's Clearinghouse, Ronco, and Shamwow released their response to Medpac data assuring their current and future clientele that regardless of any changes in law that their will be some type of  legal "work around" for private practices to "partner" (share in revenue) with referring physicians (but of course any legal agreements and potential liability, fraud and abuse  are between you and the doc group we only get a percent of what you get plus of course a "franchise" type of fee that protects your territory for this million dollar original idea that we gave you)

-APTA HOD passed the obvious: Physical Therapists shall have control over all clinical decisions relating to physical therapy.PT's in business relationships should be the exclusive decision makers.  While this would imply to me that this extends to the business relationship of "insurance contracts" and thus support the notion that physical therapy is provided by a physical therapist acting within their licensure, RC 15 which was written with this intent in mind was appropriately withdrawn (language inconsistent with intent).  Hopefully next year, we will have real "alignment"-with all APTA positions, etc. etc. supporting PT's as the exclusive provider which would should rid any trend at  promoting of medicare rules as "the way".

-CMS also released some interesting news on upcoming changes:

On June 25, 2010 the Centers for Medicare & Medicaid Services (CMS) issued the proposed physician fee schedule rule that would implement key provisions of the Patient Protection and Affordable Care Act of 2010 and update payment rates under the physician fee schedule for services furnished on or after January 1, 2011 (CY 2011). If this rule becomes effective, physicians, physical therapists and other health care professionals would receive a 6.1% cut to their Medicare payments starting January 1, 2011 in addition to the 21.3% reduction that has been delayed several times already this year due to the flawed Sustainable Growth Rate (SGR) formula. This reduction was replaced with a 2.2% update until November 30, 2010 when the President signed the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010” on Friday, June 25^th.

In addition to the projected reductions due to the SGR, CMS also proposes a multiple procedure payment reduction policy (MPPR) that would result in significant reductions in payment for outpatient therapy services. Specifically, CMS proposes to make full payment for the therapy service or unit with the highest practice expense value and payment of 50 percent of the practice expense component for the second and subsequent procedures or units of the service furnished during the same day for the same patient. The work and malpractice components of the therapy service payment would not be reduced. The proposed multiple procedure payment reduction policy would apply to both the services paid under the physician fee schedule (PFS) that are furnished in the office setting and those services paid at the PFS rates that are furnished by outpatient hospitals, home health agencies (Part B), skilled nursing facilities (Part B), comprehensive rehabilitation facilities, and other entities that are paid by Medicare for outpatient therapy services. It is estimated that if the multiple procedure payment reduction policy were implemented, payment for outpatient therapy services would be reduced by approximately 13% in addition to the projected SGR payment cut for CY 2011.



In other words, don't get to slap happy with a temporary 2.2% increase as we are coming down on you in more than one way beginning Jan 2011 including a "cascade" phenomenon-decreasing subsequent CPT codes after the first one which might cause a 13% reduction in addition to a 6.1% (can you say "health care reform") plus the 21.3% SGR.    (side note: another blog post for another time but history has a way of recurring here with the cascade ploy as many states in work comp have successfully fought and won in reversing this illogical attempt to cut fees).

Our history with CMS demonstrates why we need the physical therapist as the exclusive provider.  While on the surface, this would appear obvious-am quite sure physicians don't have a position that says "medicine should only be provided by a doctor, nurse, or midlevel practitioner'" our profession pushed CMS that only PT and PTA's can provide "physical therapy" which resulted in CMS being the only major payor that restricts PT from practicing within their scope of practice.  Ironically, many physical therapy state boards thru unfounded and puritanical nearsightedness have attempted and in some cases succeeded in opening up state practice acts and aligning CMS's explicit list.  LET THIS BE THE CASE STUDY OF WHY YOU SHOULD NEVER DO THIS.

This blog has been saying for years that it is a myth that "medicare is one of our best payors".  You cannot consider payment policy outside of their contractual language and regulations.  CMS has the most nitpick restrictions, enhanced compliance liability, documentation requirements, etc. etc. etc.  Most practices that I know spend significant resources and dollars on yearly training, auditing, and testing on medicare rules and such.  When you add the cost of this plus the cost of not allowing a PT to delegate or direct within their practice act, CMS actually ranks amongst the worst sources in payment.  When you now factor in the imminent reimbursement drop coupled with undoubtedly even more regulatory constraint, I can't imagine an environment where it will be viable to see medicare patients down the road without significant drop in PT salaries (PTA salaries will essentially be the same as PT's under this scenario since they are looked at by CMS as the same).    For those of you who still buy into medicare's rules, how would you like your salary tied to their policy and reimbursement? Unfortunately, the saddest impact will be to the growing roster of medicare patients-longer waiting times, possible "undertreatment", and a growing list of PT's who simply will opt out of seeing them altogether.

While there is debate and divisiveness on aligning APTA's governance in its positions this is something that needs to be done sooner rather than later and we should greatly support such efforts as long as they simplify the message-physical therapy is indeed exclusively provided by a physical therapist within their scope of practice.

 

Larry@physicaltherapist.com

This blog post is a product of my own conclusions-my opinion and does not reflect any associates, friends, or acquaintances of mine!

Victory for PTA's thru RC-1 Not Passing

While this blog has not been hesitant in its opinion on RC 1 and the necessity for it to fail (here and here), we have been likewise suggestive that the real issue is not the lack of PTA "voting rights" but the failed meeting of their needs.  If we are indeed a profession bent on evidence, you only need to look at the well documented APTA survey on PTA's to come to that conclusion.  Perhaps now a subcommittee of PTA's can deliberate and strategically plan for their own needs thru some organized effort and with the abundant number of resources for these kinds of things at APTA.  With 80+ additional PTA programs in the works or thru expansion, the lowest percentage of PTA membership (roughly about 6% of overall membership) in history currently stands. 

My understanding is that hours and multiple amendments were spent on this topic which is quite ironic given the low percent of PTA members. Hopefully, significant energy will be made to best serve PTA's and the debate and focus on this amendment will not have served for naught resulting in a victory for PTA's.

Thoughts?

Larry

Repackaged Drugs-POPTS twin of a different mother

A few years back, some budding entrepreneurs in California figured out how to make a bundle for themselves as well as referring docs by repackaging drugs and dispensing them in physician offices where there is an exemption to laws which prevent from owning their own pharmacy (New York and Texas specifically prohibit physician dispensing).

This practice is almost exclusively used in worker's comp because drug prices are often paid according to a formula of average wholesale sale price (AWP) plus a markup (similar to DME) as opposed to healthplans which generally have co-pay requirements, networks, and formularies which have driven down reimbursement and make dispensing repackaged drugs for the most part unprofitable for physicians.   

The rational for physicians goes along the lines of making sure that the patient gets the right drug, patient convenience, and compliance. This is consistent in physician owned PT services (POPTS) where the same arguments are used along with "I can see what is going on and I am there in case something goes wrong".  

Of course, the financial incentives are also just as clear and consistent. Since I am referring for a service or a pharmacy, I should make some money off of the deal.  Interesting that research out of CWCI (California) is showing that some repackaged drugs pricing is often 1700% between physician dispensing and what the same cost would be in a discount pharmacy.  In Florida, the cost is 38% higher than the median of the states that were studied.

Recently, Florida Governor Charlie Crist vetoed a bill which would have limited the reimbursement for physician-dispensed repackaged drugs. This blog provides a primer on this whole issue.

What I find interesting is the major similarities between POPTS and repackaged drugs on so many levels.  There is data that is irrefutable regarding financial incentives and referral patterns (average # of prescriptions per claim in Florida is 17% higher than the median state).  There is the difficulty in getting this banned legislatively (Crist's veto).  There are the arguments about patient convenience.  There is the assumption that both drugs and PT services are essentially fungible commodities.  They are both also legal in most situations.

What is strikingly different however is what is being done about it.  Apparently, many payers are putting in contractual language specifically banning physicians dispensing.  Other payors are cutting reimbursements and even others are notifying physicians that patients will no longer be directed to them if they continue dispensing repackaged drugs (in many states work comp patients can be directed by the employers to medical providers).

Sometimes we have to learn from those aligned with us and certainly the repackaged drugs industry is one of them.

Thoughts?

larry@physicaltherapist.com

ACO's Won't Work Cause "You Don't Win The Kentucky Derby with Mules"

While my lifelong devotion and suffering for the Cleveland Indians continues, my favorite vocal manager and the only one I follow on Twitter is Ozzie Guillen of the Chicago White Sox who was credited with the above quote when responding to questions about players, GM's, and managers.

This blog has had many posts regarding the propensity to make up retreaded terms and concepts to come up with easy answers to complex problems in healthcare including this post 13 months ago on Medical Homes.  The latest Lady Gaga is ACO's or Accountable Care Organizations with this month's Health Affairs offering a national implementation strategy for it.

In 1899, Charles Duell, the commissioner of the patent office at that time stated that "everything that can be invented has been invented".  I am quite sure he was talking about 21st century healthcare reform attempts.  

Here are some of the features of ACO's:

-A typical ACO would include a hospital, primary care physicians, specialists and potentially other medical professionals.  Services would be billed under fee-for-service.  ACO members would coordinate care for their shared medical patients.  ACO's might be instituted under different payment models.

-ACO's are jointly held accountable for achieving measured improvements and reductions in the rate of spending growth (as opposed to relying on insurance companies to do this)

-All ACO's would have a strong base of primary care.

-Medicare could pay ACOs with a “gainsharing” mechanism.  In the gainsharing framework, the fee-for-service payment structure remains, but a portion of patient cost savings gets passed through to the physician.  Likewise, cost overruns would occur at the expense of providers.

-ACO's may involve a variety of provider configurations ranging from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians such as IPA's.

If any of this sounds familiar, it should.  Think HMO appearing as a cross dresser and you get the picture.  The idea of tons of physicians working together and with hospitals, specialists supporting strong primary care as a base, and mutually driving down costs so they can share in bonuses has about as much chance at making it as Lyndon LaRouche does for our next president.  

The problem with concepts such as ACO's and P4P is that they sound better when you don't define them and when you do, you get ambiguity, inconsistency, and meaningless drivel.   Health Affairs  acknowledges that the lack of common understanding about what an ACO is indeed a barrier.  While there the perfunctory small demonstration that supposedly had success and the concurrent multi attempts of further pilots, when you dig deep into the details the project  system design, reimbursement, definitions of quality, benchmarks, and outcome have little in common with one another. Attempts to extrapolate nothing in common with national policy implementation is akin to entering a donkey in the KY Derby.

As one of my favorite thinkers on healthcare aptly points out, even if providers treat illness well,  how does this qualify them to price out risk?  For that matter, how well did hospitals and other integrated systems do in HMO's with taking on risk?  How well did patients like their HMO's?  The most troublesome aspect is it further removes the individual patient from decision making and discernment of their health care dollar to include being responsible for their own health.

Retreaded ideas as saviors of healthcare won't be die slowly.  While I am sure you will see various articles in all kinds of national publications on ACO's, be alerted that they are simply a horse of a different color.

Thoughts?

larry@physicaltherapist.com

Would You Get Physical Therapy if you paid 31% of the total bill?

Here is one take on the healthcare reform bill by Nobel Prize economist, Gary Becker who as WSJ points out, “has nothing left to prove”.

 "we spend about 17% of our GDP on health care, but out-of-pocket expenses make up only about 12% of total health-care spending. In Switzerland, where they spend only 11% of GDP on health care, their out-of-pocket expenses equal about 31% of total spending. The difference between 12% and 31% is huge. Once people begin spending substantial sums from their own pockets, they become willing to shop around. Ordinary market incentives begin to operate. A good bill would have encouraged that."

Let’s imagine if you had to pay 31% of a bill for your medical care.  Would you:

Question every test? 

Want to know if the physician had conflict of interest in their referrals?

Want to know less expensive alternatives to surgery, drugs, or imaging?

Would you want to pay for physical therapy?

As a PT provider, if your patients had to pay 31% of their bill, would you?

Give them a screen and then a home exercise program?

Follow evidence-based guidelines?

I don’t think you need to worry about your answers at least for now.  Instead we are going to get more and more regulation via approximately 150 new government agencies many of which are “oversight”.  This of course means more chart reviews, coding primers, and paperwork and less questions from patients on efficacy, evidence, or quality.

larry@physicaltherapist.com

Healthcare Reform-Hurry Up and Wait

Anybody read the 2500 plus words on what was voted and approved late last night?  Me either.

I do know that the debate will rage on.  There will be endless amendments proposed, nothing about healthcare reform via H.R. 3590 will hit us anytime quickly except questions asking us how it impacts us.

The only thing I do know is the following:

-we have what is called the biggest reform in 30+ years in healthcare and there isn’t much impacting PT-nor should we really expect there to be as outpatient PT is roughly 14 billion/2.2 trillion of the pie

-I see nothing addressing the soon to be bankrupt medicare system but from what I understand, healthcare will expand to 31 Million and the deficit will reduce. For that to occur, money has to be taken from somewhere including less benefits for medicare, less payments to providers, or some combination of both.  Laws of unintended consequences will likely impact all of this in one way or another

-The bill extends the never ending therapy cap exception process for 2010–Yahoo!  Why there wasn’t room in a bill of over 2500 pages to get rid of it will never make sense to me

-the 21.2% reduction in payments under the medicare physician fee schedule goes into effect April 1.  If I was a betting person, I see this being resolved or extended well before any final reform package gets to Obama’s desk

-I see nothing addressing key elements of PT-direct access or self-referral

Anybody ever run the math on 14 billion/2.2 Trillion?

larry@physicaltherapist.com

McCarran–Ferguson Act. Where do we stand?

The McCarran-Ferguson Act and repeal thereof is gaining in popularity including many healthcare professions jumping on the bandwagon since the House voted for the second time in three months to repeal legislation of this antiquated legislation.  AMA's studies as well as all of us in private practice know, competition in the health insurance industry is a thing of the past. Few companies all working together to ratchet reimbursement down and create bottlenecks for providers to access patients which at the end of the day permits price fixing amongst health insurers.  Of course, all of this is in the background of healthcare reform so it has not caught the chatter boards nearly as much as the extension of exception process or delaying the 21% cuts (side ques: why is there celebration of the passage of a 1 month delay rather than repulsion that any of this is going on to begin with?).

The AMA has taken a stand for repeal.  Where are we? Why haven't we heard from our various national associations and representation?  Is it time to play "safe" politics or is it time to see the perspective of those in the trenches trying to deal with monopolistic payors and their draconian cuts?

Thoughts?

larry@physicaltherapist.com

More Than A Tweet

but less than a full blog post and not befitting of posterous account so I thought I would put them together.

-Can’t help thinking that as physical therapists we need to formally get on the bandwagon of the very noble initiative by Michelle Obama to curb child obesity especially when one considers the substantial evidence on exercise and nutrition. Since most of our patients are overweight and that is not their primary reason to come to PT, we could play a role in this fight.  Government estimates are that obesity costs $147 billion year (or more than approx 12x the size of the outpatient PT industry) in weight-related medical bills.  The government campaign Let’s Move sure goes hand in hand with our Move Forward.

-From the latest Cochrane on use of therapeutic ultrasound for knee or hip OA:

In contrast to he previous version of this review, our results suggest that therapeutic ultrasound may be beneficial for patients with osteoarthritis of the knee. Because of the low quality of evidence, we are uncertain about the magnitude of the effects on pain relief and function.  Therapeutic ultrasound is widely used for its potential benefits in both knee pain and function, which may be clinically relevant.  Appropriately designed trials of adequate power are therefore warranted.

Looks like we might see a big return to ultrasound machines at our exhibit halls!

-at TED this week having just finished one of their books they sent as part of their book club called Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives.  'Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet and Threatens Our Lives by Michael Specter. It is an excellent book on many fronts and provided much insight as to why there really is an “anti-science” trend which by extension anti-EBP.  The unfortunate emotional arguments against clinical-effectiveness research as a plank in healthcare reform is probably the most recent showing of “denialism” in action. The recent Lancet retraction of the crazy notion of linking MMR vaccines to autism unfortunately help spread denialism to a movement that resulted in less children being vaccinated.  Specter is presenting at this conference and the presentation will then be available sometime on the TED site.

-Re-reading Nov 2007 post Support the Exception to the Moratorium of the Exception process demonstrates that some things never change. On Feb 4, Senator Ensign (R-NV) introduced 2 pieces of legislation that could extend the therapy cap exceptions process for one year (S.2987) and two years (S.2988) and most likely this legislation gets attached to others but does pose a near term opportunity to repeal the cap temporarily while we hopefully get a permanent repeal.  As PT’s it is time to reach out and I particularly recommend both the APTA legislative action center which is a brilliant way to personalize your message to your Senators and the Patient Action Center which is also a meaningful way for your patients to assist in the effort (especially the irate Medicare patients who have already exhausted their 2010 cap).  As we have consistently said on this blog, if for no other reason than legislative representation, you should be a member of your national association.

-On a very sad note a name synonymous with our profession, Werner Hausmann died in Florida at age 85 from cancer.  His equipment including tables and parallel bars adorn physical therapy centers everywhere. Here is an inspiring story about this fine man and entrepreneur reflecting his humble upbringings and the challenge that created his company.

-Lastly, I would like to get ideas and suggestions on Physical Therapists Help For Haiti an initiative designed to bring physical therapy attention, relief, and emphasis on the devastation in Haiti.  There has never been a time when the whole world will be watching physical therapists play such a significant role in so many lives and the current work of PT’s in Haiti right now is inspiring.  One initial thought was to hold an online course with several renowned instructors donating their time by teaching with all registration monies going exclusively to supplies, training local Haitians in rehab techniques, and other physical therapy relief efforts. All we have is a reserved domain name so please feel free to share your thoughts.

larry@physicaltherapist.com

Crook Post

My All PT’s are Crooks satirical post generated some comments and caused an overload to my email inbox.  The overwhelming response was positive and most found humor in it. Many shared with me interesting and compelling stories of their experiences with many of the issues addressed in the post.

My writing is a product of my own conclusions and based in large part on the increasing regulatory trend as well as more emphasis on coding and compliance training rather than evidence-based practice. The genesis of it has been influenced by discussions with private practice PT’s , comments and interpretation on various listserves, articles in our journals, presentations, participation in last years public Rothstein debate, and my work in practice management where fear over these issues are palpable.   Some of the issues (e.g. can’t open up our practice act), I have heard for 25 years.  My recent exposure to what is going on in California with PT’s caving to their state’s largest payor out of fear and the arguments that I have been hearing out of New York to PT’s who are trying to make positive changes in their practice act took me over the edge.  Let’s not forget the most obvious-this is a blog where opinions are openly shared and comments are invited.

Let me first be clear as to what the post was NOT. It is not an indictment against any individual person, CE course, company, product, or association.  The issues are an amalgamation and a reflection of what I see in practice and my concerns regarding significant over regulation and what it is doing to patient care-reducing us to technicians which ultimately is resulting in downward reimbursement rates and making private practice viability a real concern.

It is clearly the responsibility of PT’s to know “rules”. Furthermore, it is incumbent on them to not only follow them but to have systems in place that assure compliance.  On this level, it is akin to college coaches following NCAA guidelines-may not like the “rules” but they have to be obliged. It is understandable that there many courses, consultants, attorneys, and experts in this arena.  In my practice environment, we have created a “Dummies guide to medicare” complete with a quiz and annual training including corporate compliance and discussions regarding coding and billing examples.  We take the philosophy of embracing compliance as a method of improving care but do so in an unintimidating and fun environment.  Scaring PT’s and staff doesn’t benefit anybody and I have personally seen tense and intimidating environments where I believe there is too much emphasis on this stuff.  I do believe that compliance and some regulations are important cogs of the system-but further believe that the pendulum has gone grossly overboard.  For those that cry out for more regulation because of widely publicized fraud cases, they need to be reminded that in almost every case there was deliberate and malicious intent to violate the laws.  I believe that almost all PT’s want to do the right thing.

It is my further contention that the cumulative impact of all of these “rules” has caused a practice environment that I would describe as “scared” since there are way too many of them and they are often at odds with licensure and even more often conflict within different payors-thus causing more and more time to be spent discerning.  While I understand the “default” portion to just “follow medicare rules on all patients”, I think that is a disturbing trend.  All of this results in significant time in over documentation, time calculation, and coding interpretation that takes away from patient care. I would invite you to view a presentation that I first saw at TED last year by Barry Schwartz who powerfully argues how often rules fail us.  This point was driven home to me recently when I was reminded by medical providers how liberating their experience in oversees medical missions where they are unbounded by onerous regulations. 

The unintended consequence and overall impact of all this has transitioned our practice to an arbitrary salary cap, a “billable” minute service time unit that is incredibly restricting, and an on-going reduction in the ability of a PT to use their professional judgment at the same time that PT’s are now going to school for 7 years and receiving a doctorate (keep in mind that outpatient PT is less than 1% of the medicare budget) .  We have published in a previous post through the use of independent benchmark data that shows if a practice saw 100% medicare patients that the max earnings on a PT is about 70k.  Can you imagine what it is in states where routinely the reimbursement is about 60% of medicare?  States that are the most regulated (sorry New York) also have the lowest reimbursed rates. I don’t think this is coincidental but the accumulation of devaluing our services and reducing them to a set of “do’s and don’t’s”.  I don’t know of any “doctoring profession” that takes away the ability to use discretion and professional judgment the way we do in PT.   My colleagues in NY tell me that the average PT has to see 16–25 patients per day without the use of extenders to remain viable. Isn’t that a little concerning on quality care? Many in that state are adamant that they should not “true up” their practice act with the model practice act or with essentially all other states which allow for extenders.  Their claim is that this is unbecoming of a PT to use support personnel, demeaning to the profession, and other emotional arguments that at the end of the day basically reflect that PT’s are incapable of using their brains and use of discretion concerning clinical reasoning, delegation, supervision, and direction of services.  Isn’t it at least a little odd that in environments like the military and sports medicine, where direct 3^rd party reimbursement is not of concern and outcome is of most critical importance that they liberally use support personnel under the direction of a PT (and those environments have a very high percent of board certified specialists, published research, and residency trained PT’s) .  We are seeing great examples of PT’s teaching rehabilitation techs in Haiti right now of basic procedures and interventions since there are clearly not enough PT’s to go around such devastation.  Do the same PT’s that think PT’s should never use extenders likewise see these unlicensed rehab techs as demeaning to our profession?

Some further examples of practices paralyzed in their attempt to follow the rules:

PT’s who don’t bill for all they do under the mistaken view that that they are being “nice” or not at risk for compliance problems. 

Applying medicare's superimposed rules to all payors and believing that all care has to be 100% direct on one one between a licensed PT or PTA and a patient (by the way, if that is your belief that is fine but please stop telling everybody who doesn’t follow your belief that they are not ethical)

On non-medicare patients, not using support personnel on any aspect of patient care because of the mistaken belief that AMA CPT codes don’t allow it and that the codes trump state practice acts and licensure

Counter-intuitive definitions for things like “group therapy” including bizarre scenarios of what you have to bill when you have a medicare and a non medicare patient having overlapping times

Not billing manual therapy if it is less than 8 minutes

State associations not trying to make modifications to their practice acts under the very strange belief that opening them puts them at risk for losing certain privileges

If my crook satire post results in PT’s being less “scared” in their clinic environment, charging for exactly what we do, not signing contracts below cost, and creates movement towards ending further regulation and rolling back existing ones that impair patient care then it will have been successful.  Judging by the many emails that it did in fact both strike a nerve and made people laugh, I deem it already successful!  We should deliberate and debate these issues openly in the hopes that it drives real change.

Lastly, I obviously don’t believe that all PT’s are crooks.  Like any profession, there is a very small minority that ignore the rules and an even smaller minority that blatantly practice against them and commit fraud. I don’t think it is helpful for the overwhelming majority of PT’s who follow “the rules” to get more “rules” simply because of the vocal minority.  We have “regulation fatigue” and should be resisting further changes and fighting to ratchet back the many we currently have.

thoughts?

larry@physicaltherapist.com