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CMS Proposal for Policy and Payment Change in 2010

What do these potential changes mean for PT?  I haven’t a clue-do you?

Some of my takes:

-we are still looking at a 21.5% reduction in 2010 but it might actually be more given the “redistribution” in codes which have to be balanced. This might mean that it could be a more draconian cut than 21.5.  On the other hand, we have been exposed to supposed cuts since 2002 and yet a reprieve has always occurred.  The whole SGR has faulty premises acknowledged by almost everybody and in the context of bigger reform, I would have a hard time believing that something won’t change

-looks like specialists won’t be getting bigger bucks for “consultation” and will have to take the E&M route and this reduction will increase primary care type of payments by 6 to 8%.  (note for file:  check again why PT’s are one of about 3 practitioners left that cannot bill using E&M)

-in what might be the most crafty strategy that I have ever seen CMS devise, they are going after referral for profit imaging by decreasing payments and wanting outside accrediting bodies to credential imaging services!  There are other regulation suggestions on this 2 part initiative and MedPAC and GAO have obviously substantial data that suggests overutlization of these hi cost drivers.  The big question for us as PT’s-why can’t they extend this same philosophy for other conflict of interest scenarios like physical therapy centers?  Could an MD owned PT clinic withstand even rehab agency survey yet alone something more onerous like CARF? (note for file:  find out why our national association doesn’t list this as a hi priority for their healthcare reform position)

-PQRI, the voluntary reimbursement cut that almost nobody is doing is going to expand the number of measures and seek the ability to utilize systems contained within an EMR in an effort to streamline efficiency

While this is not an exhaustive list, these appear to be the major points of the proposal.  keep in mind that it must go thru comment periods and will undoubtedly have major changes in it prior to implementation at some level in 2010. Likewise, while all this is occurring, the national debate and potential massive reform legislation continues.

larry@physicaltherapist.com

A Rally For a Better Strategy-Questions, Questions

While only 603 participated in a virtual healthcare rally done by APTA, it is certainly a good start and a unique way to get the troops corraled.  It is also laudable that the collaterals and position of PT perspective in healthcare reform have been published. Unfortunately, they provide as much excitement as the fine print on a mattress tag.

We have documented in the past that what is missing from these efforts is the advocating for the wrong audience.  Reform is supposed to be about addressing societal needs. 

While I acknowledge that I have more questions than solutions for these complicated issues,let’s get some strategic thinkers, marketing experts, and PR folks engaged in the content development and it's presentation.  As PT's, we can’t hang our hat on a host of legislative success in recent years-particularly the big issues like direct access in medicare which is going on approx 10 years and the eliminating the medicare cap which has probably been around longer than fax machines. So how about a different approach?

Some questions:

Why instead of writing in language clearly meant for lobbyists and healthcare wonks don’t we write something that every American can understand and something that resonates with the day to day patient care lives of PT’s?

Why is wellness and prevention the highlight and apparently the priority?  How many PT’s actually do the example cited in the document of “for patients who are obese, physical therapists develop programs that can balance the progression of exercises with the need for joint protection and safety”?

How about how PT’s can help the approx 50 million without insurance by being used in the much needed role of musculoskeletal evaluator and extender of care for primary care physicians? Why shouldn’t we use great examples like US military system, sports medicine, and many employers models where PT’s are the front line?  Aren't PT's capable of assisting in the innovative solutions like this Fast Company article points out about Walgreens?

What about supporting policy that addresses a principle driver of healthcare costs-notably conflict of interest that is well documented and highlighted in current discussions on healthcare regarding imaging but there is seldom a mention of PT and other over utlilizers like DME and surgical centers?  We could provide well documented examples and although it is far too late, provide funding for research in this area (note to Foundation for Physical Therapy-very disappointed in the lack of funding i after raising money for this clearly identified high priority effort only to have it put back on the backburner where it will undoubtedly be too little too late).

The mention of comparative effectiveness research is great but please bring it to life.  What about the utilization rates in spine surgery and the cost effectiveness of physical therapy interventions for LBP and knee osteoarthritis?  Perhaps a few testimonials?  Can we find a consultant who writes informercials?

Why even mention PQRI?  It’s adoption rate by PT’s is dismal and the program is a reimbursement cut for any of the disgruntled that are participating.

I sincerely hope there is a next rally-with materials and a strategy that is exciting and can create exponential numbers of PT’s carrying the banner of being part of the solution to healthcare by understanding the needs of the real stakeholders-the millions of those that are without insurance and the hi costs to those that provide insurance to their employees.

Thoughts?

larry@physicaltherapist.com

Health Care Reform and Physical Therapists

When I hear "rally," I immediately envision "rally caps" and baseball and the hope and excitement of a cohesive team coming from behind to win the game.

So, okay, what I envision when I hear "rally" is very, very different than a "virtual rally."

This evening the American Physical Therapy Association hosted a "virtual rally" to help physical therapists make an impact on health care reform.

By October 31, 2009 President Obama wants a bill on his desk for him to sign.  He's waiting for a health care reform bill that takes into consideration his suggested 8 principles.

Do you wonder how the American Physical Therapy Association is representing physical therapists?  The APTA's perspective isn't a secret.  That page doesn't have too many details, but this paper on the Role of the Physical Therapist in Health Care Reform is a bit more detailed.

The APTA panel did an excellent job disseminating current information.  The rally could have been much better with less time disseminating information and more time entertaining questions and energizing participants.  Maybe my problem was I wasn't wearing my "rally cap?"   Maybe the real issue is that a "virtual rally" isn't the time or place for "rally caps?"

Every one of us needs to put on our rally caps because we have a role and we need to have our voices heard.  First, we need to stay current and pay attention to all the various proposed changes that will be discussed and debated in about 6 weeks.  The APTA created a Health Care Reform resources center updated with current information and podcasts.  It isn't enough to just read and stay current, the next step is to get involved.  Members can use the Legislative Action Center within the above link.  Nonmembers and consumers can use the Patient Action Center to become involved and have their voices heard.

Now is "rally cap" time... put them on... choose to let your voice be heard!

photo by sportsstan via Flickr

~Selena

Random Thoughts About Healthcare

Since healthcare will undoubtedly be in the news for the next several weeks, I thought I would list some random thoughts.

-healthcare, medical care, and health insurance are 3 different concerns with some overlap between them.  When those that bad mouth our medical care site the decrease in life expectancy of US and other “health” measures, they clearly don’t know the difference.  Attempts to solve all 3 at once thru one sweeping legislative is a little naive in my opinion.

-while I can find a lot of valid arguments against a gov’t run single payors system, the oft cited “we don’t want beaurocrats making medical decisions” shouldn’t be one of them.  We already have that with every major private payor in the U.S. 

-I don’t understand the logical deduction that many are making when they state “comparative effectiveness means rationing of healthcare”.  If we don’t have some analysis, we might continue to have some chiro’s continuing to treat kids for bed wetting.

-The idea of mandating employer coverage for health insurance is completely unfounded. When are we going to realize that the employer model of health insurance hasn’t worked and won’t work as business challenges are daunting enough.  Employer model has been around for a long time and has essentially made big companies financially vulnerable and contributes significantly to increased cost of products/services and lack of companies being able to expand.  The vast majority of new jobs are created by small business-mandating insurance coverage might stop a new business in its tracks before it starts.

-There is plenty of money in the system to take on the 50 million without coverage but there isn’t enough providers.  Therefore, without force multipliers and deregulation around those that can provide services, there will be long lines and general angst.  The military healthcare system has been dealing with these issues for years and its system should strongly be considered as a model.

-given the hi percent of GDP on medical care, I do believe that a catastrophic health benefit should be a birthright and affordable primary care should be available.  The one thing you can say about medical care-even at its worst-there are true economic transactions and people performing services which is good for the economy as those employed do pay taxes (will avoid commentary about the failed bank crises and their number of employees by comparison).

-You can’t have healthcare reform without legal reform and business reform.  Significant cost drivers include “defensive” medicine and fee for service in “conflict of interest” business arrangements. The hidden cost of regulation contributes to to the problem.

-Consumers already exhibit a strong voice in their care.  Per FDA data, 70% of the time a patient requests a certain type of drug from their doc, they get it.  The idea that individuals can make complicated decisions about spending their dollars makes no sense at all.  Increased co-pays have not solved the problem and in many cases are counter-productive towards savings.

-There are generational differences in medical care. Older baby boomers generally trust their doc, younger generations are skeptical about their medical providers and they are comfortable doing searches on the internet to help them determine their best care.  They also want a CNET style of healthcare which will show them number of choices, lowest cost, and provider ratings. 

-Anybody who believes the gov’t knows how to implement “quality standards” ought to read about the adoption rate of PQRI by MD’s and PT’s.

-Not sure I understand why we aren’t looking at the success of mandating individual auto insurance as a model. This substantially opened the market to individual underwriting and competition which is something we don’t have in the health insurance marketplace.  Many employers would be happy allocating to an individual an amount of money for them to choose their own policy outside of their employer.

Thoughts?

larry@physicaltherapist.com

Glad the OMB reads the New Yorker

I read with great interest this blog post from the Office of Management and Budget’s director Peter Orszag about tough questions from healthcare including how expansion will be paid and what types of innovation needed to be pursued.

Thankfully, Mr. Orszag not only read Dr. Guwande’s great article regarding the excessive cost of healthcare in McAllen, Texas, he pursued additional information as well.  Why does McAllen spend almost twice the national average per medicare enrollee ($15,000) and almost $3000 more than their per capita income? Overutilization driven in large part by physician self-interest particularly their “business” interests.  There is also no doubt that overutilization is also driven by defensive medicine and aggressive attorneys coupled with a fee for service system that encourages more over better.

Mr. Orszag’s blog lists categories of innovation that will be part of changes including IT, “effectiveness” research, prevention and wellness, and changes in incentives that assures best care and not more care. 

My hope is that as PT’s we don’t get sucked into trumpeting ourselves as the “prevention and wellness” profession.  Let’s not kid ourselves, that would not position us in a major way in reform and attempts to do this should be challenged.  Instead, we ought to push a proven model of PT’s as important provider via extenders in musculoskeletal medicine.

If we are to put an additional 50 million people in the system, we need proven models and deregulation that allows PTs to be used as force multipliers as the current system due to physician shortage cannot handle this additional load.  We ought to be trumpeting the exemplars of PT-namely the US Military System as THE model for healthcare.  We don’t need to look to socialized countries or any other “experiment”-the best example is right in front of us.

Military medicine works off of the theory that there are too many people who need care and not enough providers.  PT’s have been providing direct access, primary musculoskeletal care for years in the military settings for both active duty, retirees, and dependents.  In some cases they are granted prescriptive authority for both meds and imaging.  It’s a system that works in large part because the government absolves themselves of all the rules they place on us in the medicare system.

As debate unfolds, be leery of the trap to push us forward as “wellness and prevention” experts. Our best position in reform is our efficacy, cost-effectiveness, and expertise is in musculoskeletal medicine.

Thoughts?

larry@physicaltherapist.com

PT's Should be able to out of Medicare like everyone else

Act Now or Forever Hold Your Peace!

 

Healthcare reform is moving fast and furious, and private practice in physical therapy is in serious jeopardy of becoming obsolete.   While it may make sense for certain portions of our profession to be included in a broad-based, subsidized system (e.g., acute care PT, and PT for long-term, chronic disabilities), private practice is more likely to be washed away.  The current healthcare environment is already a threat to independent practices.  Reimbursement rates from the insurance companies are insufficient to support a small business model that focuses on individualized care over high volume and access to the most qualified provider to meet patients' needs rather than the least qualified service extenders.  

 

While the current healthcare system creates a monopoly environment in which hospitals get reimbursed at a higher rate than the same service provided by an independent practitioner (e.g., outpatient physical therapy), we are able to survive because we can opt-out of the network.  We cannot, however, opt-out of Medicare.  Certain providers, such as physical therapist, do not have the legal standing to opt-out of Medicare.  So, if a physical therapist does not participate, they cannot provide services.  If the public plan is modeled after Medicare -- those restrictions are likely to continue or be expanded, and will include larger numbers of consumers.  Furthermore, private insurers will follow suit in their restrictions (they already have -- rendering escalating penalties to consumers who step out-of-network, and providers who refer out-of-network).  The unintended consequence of using the Medicare model for an expanded government healthcare program will be to force many small business healthcare providers to close their doors.   Communities across the country will be negatively impacted in terms of significant job loss as practices close and decreased access to quality healthcare providers.

 

Healthcare reform must include an element of the free market system that relies on transparent competition among providers to render the best care possible. Not only are transparency, consumer choice in insurance plans, and direct access to providers critical, so too is the right of consumers and providers to step out-of-network to support outcomes-driven excellence and sustainability in small-business healthcare practices

 

Our legislatures need to hear from small business owners in the healthcare sector.  We cannot rely on others to speak for us or the entrepreneurs who drive innovation and excellence in the marketplace will have no place to go, but home.   Please follow the link, and sign the attached petition today!  Let's send 10,000 voices to Congress on June 26th, 2009. 

 

http://www.ipetitions.com/petition/choosephysicaltherapy.

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~

Jennifer M. Gamboa, DPT, OCS, MTC

Reduced Treatment Time on LBP from 66 to 12 Days

Another article regarding Seattle’s Virginia Mason Hospital and their use of the Toyota Production System Model to re-engineer healthcare.  Primary example is getting a patient in for low back pain right away avoiding MRI and specialist referral.

Physical Therapists can have a huge role in health care overhaul as we are the force multipliers of musculoskeletal medicine.

We need more of these examplars during as the current national debate continues.

larry@physicaltherapist.com

Summertime PT Regulationz Quiz-redux

Had a few requests to republish this from a year ago. Perhaps some want to improve their score!  Even added an additional question.

It is time for the first annual “are you smarter than a PT regulator?” test.  We will start out with a sample question and then get right into it.  Please do not look at the bottom for the answers and explanations until you have completed the test.  Be honest, post your scores and your thoughts.  If you are too scared to post them on the blog, please email me privately.  Academic programs-particularly interested in how your students performed.  Perhaps it might be better for them not to take this since it might scare them out of the profession!

I realize that PT’s are exam phobic. However, I thought this was the best way to illustrate the absurdities in our industry.  Sorry in advance for the length of this blog post.

Sample Question:

Which of the following are the only providers under medicare’s rules to have a physician signed plan of care:

A. Chiro’s

B. Optometrists

C.  Physical Therapists

D. Dentists

E. Proctologists

The answer is C of course.  Why don’t we fight against this? who knows. In fact the recent change from 30 days to 90 days has caused more confusion and questions than it has answers, particularly the physicians who are now asking questions about plans of care that last 10 weeks!!

 

Medicare Physical Therapy Economics:

1. Which of the following received the most payments in medicare for PT services:

A. Hospital

B. Skilled Nursing Facility

C. Physical Therapist Private Practice

D. Physicians

E. Outpatient Rehabilitation Facility

 

2. Hospitals have always been exempt from the medicare cap.  Between 2004 and 2006 which provider setting has seen a decrease in percentage of medicare beneficiaries seen in their setting:

A. Skilled Nursing Facility outpatient (medicare part B)

B. Hospital Outpatient

C. Physical Therapist Private Practice

D. Outpatient Rehab Facility

E. All but C.

 

 

3. Approximately 8.5% of the 43 million medicare patients annually access PT. What percentage of the 179 billion part B medicare budget goes to PT?

A. 2%

B. 4%

C. 6%

D. 8%

E. 10%

 

4. There were approximately 4% more PT’s seeing medicare patients in 2006 than in 2004. This resulted in the following:

A. about a 4% rise in physical therapy expenditures in 2006

B. a 10% rise in 2006 sending all kinds of “red flag” to medicare about PT usage

C. There was no change in expenditures between 2004 and 2006

D. There was more than a 5% decrease in PT expenditures between 2004 and 2006

E. None of the above are true

 

Medicare Regulations:

5. Which of the following are not allowed as billable time under medicare:

A. A ventilator dependent skilled nursing patient is in being treated by a student under supervision of a PT.

B.. A ventilator dependent skilled nursing patient is being treated by a therapist extender under supervision of a PT.

C. An ATC working as a therapist extender is counting the number of straight leg raises of a medicare patient.

D. A physical therapist assistant working solo in an outpatient rehab facility is performing manual therapy on a patient.

E. PTA working solo in a outpatient rehab facility is doing soft tissue massage

 

6. A PT is working with a medicare patient.  After examination and applying a clinical prediction rule, the PT decides to do a manipulation thrust technique on a patient which after looking at his clinic supplied (and CMS approved) stopwatch took 5 min.  Concurrently, a therapist extender is working with a non medicare patient counting the number of straight leg raises.  What is the correct billing?

A.  Wow, too difficult to tell-so I will take the safe route and bill it as “group” or not charge at all

B. A no charge on the thrust technique since it took less than 8 minutes.

C. Assuming the pre and post treatment times are added to the stop watch, it is a safe assumption that it took 8 minutes BUT the concurrent patient was being supervised by the PT so the thrust technique is “group” therapy.

D. Manual therapy thrust techniques are not allowed on medicare patients-at least not in my clinic.

E. This scenario is stupid. It is immoral, unethical, and impossible to manage more than one patient at a time and the fact that you have even used the words therapist "extender" is a disgrace to our profession-am done with this stupid quiz that I am failing.

7. Which of the following are part of a typical state practice act in PT:

A. Certification plan

B. 8 minute rule

C. Restriction on billing for work performed by students in an outpatient setting

D. Explicit definitions of PT and PTA as the only providers of service

E.  None of the above

8. Which of the following according to CMS are not allowed to make “clinical judgments”?

A. PT

B. PTA

C. ATC

D. Therapist Extenders

E. All but A

9. Which of the following payors most restrict the clinical judgment of a PT?

A. CMS

B. United because they pay the least.

C. Work Comp

D. Private payors in general

E. None of the above.

10. Many hospital PT’s are very concerned that effective July 1, PT extenders under direct supervision will not be allowed to work with medicare patients and have their “minutes count”.  Which National Organization has lobbied for the continued use of therapist extenders in the part A environment:

A. APTA

B. NASL

C. AARP

D. ASPCA

E. NAFTA

11. After Nuclear Power plants, which industry is the most regulated:

A. Health Care.

B. Construction.

C. Insurance

D. Financial services

E. Pharma

12. Which of the following will most help Tiger Wood’s with pre-op exercises?

A. Self-help DVD

B. An exercise sheet of knee exercises given by a physician with a popular anti-inflammatory as the sponsor of the exercise handout

C. a Nintendo Wii

D. A therapist extender under supervision of a PT after a clinical exam by the PT

 

13. A Senior PGA tour player who has medicare has just been referred to PT for knee pain.  Which of the following are not considered billable?

A. A therapist watches a self help DVD with a patient

B. A PTA reviews the exercise sheet given by a physician

C. PT plays Nintendo Wii bowling with a patient

D. an ATC (therapist extender) under supervision of a PT and after a clinical exam by the PT is working with the patient on straight leg raises

E. all of the above are billable under medicare

 

14. All of the following are supervision terms used by medicare except:

A. General Supervision

B. Direct Supervision

C. “line of site” supervision

D. “same room” supervision

E. All are terms used by CMS

 

15. Hospitals are exempt from medicare’s cap for outpatient PT.  This is because:

A. Hospitals are the preferred provider of CMS

B. Hospitals have shown that they are the most cost-effective providers of outpatient PT

C. Hospitals have always believed that all PT should be “one on one”

D. Hospitals have the lobbyists with the biggest bucks and biggest influence in Congress.

E. Nobody really knows-just another stupid rule by the government

 

16.  The medicare cap for PT is combined with speech and language pathologists while OT has its own cap.  The reason that it is combined is:

A.  Everybody knows speech therapists really want to be PT’s so they just went ahead and combined them

B.  Allows co-treatment of PT and Speech without regards to total dollars

C.  So few outpatients need speech that they figured “what the hell, let’s just combine them”

D. They knew they couldn’t combine PT’s with OT’s or there would have been a hell of a dogfight

E. Nobody really knows-just another stupid oversight by the government

 

17. PQRI is a CSM volunteer program that pays a financial incentive for participating outpatient clinics. Which of the following about PQRI are true:

A.  Very few providers are using and the majority of those who have submitted for the payment have not received

B. Per CMS website PQRI is evidence-based and prepares providers for pay for performance initiatives

C. Other than the EIM blog, there has been no criticism of PQRI by representatives of physical therapists

D. The cost of implementing PQRI is much greater than the increased reimbursement by CMS for doing it.

E. All of the above are true.

 

 

ANSWERS:

1. C.  PTPP dominate the medicare outpatient physical therapy world with a 35% market share with hospitals having 21% and physicians 9%.  Although PTPP is by far the largest, it cannot be determined how much of PTPP is truly outpatient PT owned by PT versus outpatient PT that is owned by MD’s.  We do know that the biggest rise between 2004 and 2006 data was PTPP and it is presumed to be physician owned growth since that is when MD practices were allowed to start applying for their own PTPP numbers. In fact, physician data to CMS actually decreased during this same time due to the transition of MD practices billing “incident to PT” to PTPP.

2. E.  All  but PT in private practice have seen a decrease in the number of medicare beneficiaries in their setting.  Right wrong or indifferent, physical therapy private practice is where the medicare “action” is yet the ridiculous superimposed rules by CMS are making financial viability in a private practice challenging to say the least. I am sure there are several reasons why medicare patients don't go to hospital outpatient clinics for PT even when they have a financial incentive to do so.

3. A.  In fact, it is less than 2% at 3.05 Billion.

4. D.  Per CMS data PT expenditures went from 3.23 B to 3.05. They are trying to credit the medicare exemption process. Grade them an F for terrible analysis.  This is surprising since hospitals are exempt from the cap but then again, hospitals are losing substantial market share in outpatient PT.

5. C.  CMS allows students and therapist extenders on part A medicare but not part B. Don’t try and figure it out-logic won’t work.  I have no trouble with the therapist extender in these settings as  I fundamentally believe that PT’s can and should be in the position to make those determinations.  Unfortunately, the trend within our profession is to eliminate all therapist extender positions within an outpatient setting under the mistaken belief that the care is “unskilled” or that all PT requires “clinical judgment”.  Their stupid argument goes something like this: Why should an insurance company pay for services that are “unskilled”?  Is taking height, weight, and blood pressure skilled? (ok, sorry about a “quiz within a quiz”).  Does medicare pay for those services in conjunction with a physician’s exam?  The only factor that should matter to any payor is whether or not the PT is acting within their scope of practice.  Just because something is “skilled” is not the benchmark for payment as any profession has to have support services and a complete inability to pass the cost of the support services along so that a therapist can be more efficient destroys the utilitarian ability of a provider and the ability to be the most cost effective.  Don’t all professionals have support staff that assists in an overall delivery?  Lawyers use paralegals or clerical help that they bill for as do accountants and almost all other “real” professions.  On the one hand, we want to be the Vision 2020 Doctoring “profession”. On the other hand, we want to police ourselves out of an industry under the mistaken belief that we need to "clean" ourselves up or that it is immoral professionally to use support help.  Let’s fight for consistency in all settings which allows PT’s to use their judgment in accordance with their practice acts and keep in mind most practice acts have provisions for support “extenders” which calls for some level of competency and review of competencies. 

6. C but this question would not reach the threshold of psychometric properties since answers would be all over the place and it would have to be tossed out of the test.  The number of similar type questions are constantly being asked and debated in clinics and listserv’s throughout the US.  What a waste of time.  PT’s don’t go to school to figure out some counter-intuitive definition of group therapy.

7. E.  All of those are part of the medicare superimposed rules that are breaking the backs of PT’s.  We get so used to them that we often think they are part of our practice act.  Shame on us.  We need to fight for their elimination rather than passively sit back and have CMS keep adding them towards our extinction.  We also need to restrain the efforts by many in our profession who are actively promoting CMS as the standard and are pushing for all payors and practice models to adopt them as standard.

8.  E. Per CMS’ own language   PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.” Since we know therapist extenders can’t likewise make clinical judgments why don’t they let their work count since they are allowed in almost all state laws?“

9. A.  Most practice acts allow for the use of therapist extenders provided they have received training and an annual review of competencies.  By disallowing therapist extenders (outpatient only under CMS) they restrict the therapists decision making in delineating what it most cost-effective resource that should provide intervention.

10. B. The National Association for the Support of Long Term Care.  Why hasn’t APTA stepped up to plate on this?  Perhaps they are too worried about the politics of “taking sides” in an organization that is split on the use of extender issues.  My take is they have no guts.  A simple and defensible position ought to be “We believe that PT's are fully capable of acting within their scope of license within their state practice acts.  In regards to the use of extenders, provided their state practice acts allow for this, we defend a PT’s ability to make clinical judgments for the patient's best concern”.

11.A.  This one isn’t even close.  More federal and state regulations for health care than any other industry than nuclear power!  Think of HIPAA, ADA, OSHA, corporate compliance, etc. etc. As an aside, nuclear power plants have a problem called NIMBY (not in my backyard).  Perhaps CMS doesn’t want a PT clinic in your backyard either!

12. D.  Hope there is little debate on this one.  My assumption is that a room full of academics and practicing PT’s would come to the same conclusion.

13.D.  Crazy world we live in.

14. E.  Aren’t you glad you went to PT school to learn at least 4 different types of supervision!!

15.  E.  Lots of speculation, no real explanation.

16.E.  PT represents over 75% of all outpatient therapy spending.  It makes sense to combine its cap right?

17. E.  What more can we say?

Post your grades and your thoughts please.  Hopefully many of the question will irritate you and perhaps even convince you to come onboard a grass roots movement to “operation restore PT”.  We have let regulators “gone wild” on our profession and need to restore logic and reason to rules and regulations so that we can spend time providing the best in evidence-based care to our patients rather than worry about “line of sight” supervision and determination of “group” therapy.

larry@physicaltherapist.com

 

Implementing Evidence

 A policy change to clearly outline defined care, based on some level of evidence, should be viewed positively.  I'm completely horrible with geography, but I believe the United Kingdom began an initial step toward defining the care options for people with low back pain this month.  It is a bit difficult for me to easily understand politics or the medical systems in other countries, but this change did appear to have reasonable evidence to support the options for care.

The next day, crap hit the fan.  The public had its own perception.  Since painkilling jabs (routine facet joint injections) were not included in the options for care, this was interpreted as cutting corners and costs.  Granted, sure, costs were being cut but the rationale was because of the lack of cost effectiveness.  I also noticed a vibe.... people in pain deserved painkilling jabs. 

Obviously, our health care system needs an overhaul.  If policies were to change based on cost-effectiveness and outcomes, how could the changes be implemented such that public support occurs?  How can new policies have positive public perception?  Is public perception accurate with the belief that people in pain deserve whatever it is that they want?

~Selena

Quality Initiative within CMS is an Optional Reimbursement Cut

I am referring to the Physician Quality Reporting Initiative (PQRI). 

This voluntary program provides financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the medicare fee schedule.  You have to gather approved measures on at least 80% of appropriate patients and submit the specified quality-data codes for services paid under the fee schedule during the reporting period.

Per CMS website:

“Eligible Professionals have the opportunity to use participation in the PQRI program to improve the care of the patients they serve through evidence‐based measures that are based upon clinical guidelines. Participating in PQRI is a way to prepare for future pay‐for‐performance programs.”

I can’t understand why more legit criticism isn’t leveled at this initiative.  It’s as though we are giddy celebrating as a profession being part of it simply because we are included like MD’s as part of this nonsense. 

PQRI really is an optional reimbursement cut. There is talk of making this program mandatory.  The cost of administering it properly including training, compliance, integration, and auditing for clinical and billing staff far surpasses the percent reimbursement (with caps) that you get back from CMS (or if you get back).  It is yet another example of those that have no clue as to clinic operations imposing their puritanical and philosophical views on the operators that are left having to deal with the details and execution of this misguided directive.  (side note: the response to criticism yields a predictable kneejerk “but its a start and we are included with physicians” response).

Here is a good test for PQRI now that it has been around for awhile (please comment):

1. How many practices have integrated PQRI?

2. Have you received any reimbursement for PQRI efforts by CMS?

Most practices that I know aren’t using PQRI. The one’s that I know either haven’t gotten paid a penny (much greater than a year in the waiting) or received de minimus only after multiple appeals which further increase the admin cost of the practice.

This doesn’t by any means suggest that practices not integrating PQRI are lazy or unconcerned with quality.  They are simply using standardized outcome instruments on all patient populations (not just medicare) or participate in a national process like FOTO. 

Let’s not let the consistent lack of criticism of PQRI be viewed as support of this “quality initiative”.  Let’s call it for what it is-an optional reimbursement cut.

Your thoughts, experiences, comments, and answers to the above questions are appreciated.

larry@physicaltherapist.com