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

It is Now Time to Introduce The "PT Fix"

Every year, a good sized group of physical therapists gather to discuss, debate, and present issues that impact private practice physical therapists.  The "Graham Sessions" has become a great venue for many things-including a great spot to grouse about all the threats impacting the profession as well as the presentation of new and different ideas.  The Private Practice Section (PPS) originated the concept with support from APTA .  Last fall, a special regional Graham Session included sponsorship by the newly formed Physical Therapy Business Alliance. The concept for EIM's Executive Management Program in Private Practice in part originated out of these sessions and continues to enjoy a great strategic relationship with PPS.  This year there is an added dimension with short TED like talks.  I was asked to do one and originally consented until I found out that it was next to a weekend of the RC-3 Task Force (it has another name which is quite long and impossible to remember) and just weeks before CSM and Foundation for Physical Therapy meetings where I am privileged to be a Trustee.  In other words, I just can't justify more time on the road for volunteer work!  However, I do want to present my idea which I am calling the "PT Fix".

For the last 15 years, the formula used to determine how much doctors  (and us PT's) get paid has not kept up with the growth in health-care costs.  Very predictably over the years (sometimes even 30 days or most recent 2 months), Congress has reliably passed a "doc fix" and additional funds are found to cover the shortfall, in some cases actually providing a slight raise.  The root of the problem is in the formula called Sustainable Growth Rate (SGR).  Medicare in their own stupidity used their 1990's spending as a baseline that when combined with their prediction in overall economic growth would serve as the future medicare budgets.  While reminiscent of the former commissioner of the U.S. patent office, Charles Duel's quote in 1899 that "everything that can be invented has been invented", the formula never factored innovation in healthcare or an aging population that not surprisingly causes health costs to outpace the general economy.  The impact is devastating economically leaving the entitlement of medicare with multi-billion dollar shortfalls.  Rather then get to the root of the problem (a recurring government theme) the options when medicare money runs out include cutting doctor's pay or provide additional funds.  At least twice in the past three years, their has even been a creative in between solution felt by those in private practice during the August months when they delay payment so that it can carry into a new fiscal year.  The most fruitful year of the "doc fixes" was 2010 when there were five separate fixes, none longer than six months.  In 2011, the "doc fix" cost $19 billion.

The Obama administratively has endorsed repeal of the SGR formula as well as essentially every professional medical society.  This is obviously more easily stated than done when you factor in that CBO estimates that it would take an additional allocation of $300 billion which is harder to find than snow in Colorado this year.  My opinion is that this theatre of the absurdity will continue for awhile, not exactly a Nostradamus prediction.  Of course, PT's who are incredible at grass roots efforts will get numerous emails encouraging them with form letters and scripts to write their legislators and extend the "doc fix" when it sets to expire in under two months.  Along side of this effort, will be instructions on extending the exception's process-something that I started writing about its craziness in Nov of 2007 which you can view here and here.  While it's analogy to the "doc fix" is uncanny, it doesn't have anywhere near the economic implications.

My idea is the "PT Fix".  Under the premise that don't complain about a problem unless you have a solution, I would propose that we have CMS eliminate the group therapy code-97150. According to CMS' 2010 data, this code was allowed 674,473 times and CMS paid out over 10 million dollars.  The problems with the group therapy code are the fear of using it, its counterintuitive definition, cost of compliance and monitoring, and the high variability of its use or lack of appropriate use.  My personal experience and review show that it is likely used too little with this CMS "billing scenario" document adding to the confusion and fear. Along with eliminating the code, CMS would also amend their explicit provider rules and allow PT's to act within the scope and their authority.  Part 2 of the "PT Fix" is amending the inconsistent CMS document: Skilled therapy: Benefits Policy Manual, 100-02, Chapter 15, Sections 220 and 230.  This is the document that defines everything from PT to Non-physician practitioners (NPP) and everything in between and introduces my number one pet peeve in the world, the term  "skilled" physical therapy. While you would need the largest super bubble bub's daddy gum, to stay awake while reading this document, you can't help notice a recurring theme of referring to "licensed or otherwise regulated in the state in which practicing" regarding a practitioner's scope and authority.  Simply removing the document's explicit provider list of "skilled" physical therapy would allow PT's to practice within their licensed craft.  There is plenty of precedence for this-namely physicians who would never allow the creation of such superimposed lists. By the way, here is the Policy Manual's definition of Qualified Professional of physical therapy and many will find the list of available providers surprising:

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.  Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.  Assistants are limited in the services they may provide (see section 230.1 and 230.2) and may not supervise others.

Part 3 of the "PT fix" is the easiest. The therapy cap and exceptions process should be eliminated.  CMS' own data show that despite a competitive advantage that hospital's have had by not having a therapy cap, there continues to be less patients accessing hospital based departments.  In 2010, independent PT's had about $1.7 Billion of the approximate $4.5 of the outpatient therapy pie and it is unknown which part of "independent" is really self referral as this blog has discussed.  What we do know is that physical therapy overall is a very small part of the CMS outpatient expenditures with only 5 codes even showing up in the top 200 CPT codes that CMS paid (no breakdown of those 5 codes to determine if licensed PT was the provider).  While I believe a part 4 of the "PT fix" should be direct access, it has already been proposed and its only successful sniff has been a proposed demonstration project in a supposed CMS innovation center.  Therefore, I won't spoil "PT Fix" with an initiative that has been attempted.  We want this to be fresh.

To summarize, the "PT fix" consists of savings in the form of elimination of the group therapy code with amending the language of qualified professionals in the CMS benefits manual and elimination of the therapy caps and the current exceptions process.  In the lingo of TED, which has inspired these type talks at the Graham Sessions, I believe this is "an idea worth spreading".

@physicaltherapy

Another POPTS View and Smoking as an Underused tool in Endurance Training

While I am not a regular reader of Advance Magazine for Physical Therapy & Rehab Medicine  (and I doubt this blog is in their RSS reader),  it was with great interest that I read "Another POPTS View.  A healthcare attorney challenges the APTA's campaign against physician-owned PT services".   The article was strangely reminiscent of a published study which clearly demonstrates that cigarette smoking is an underused tool in high performance training.

The study on runners does an excellent job of documenting numerous research which demonstrates that cigarette smoking has an impact on three factors related to endurance performance: serum hemoglobin, lung volume, and weight loss.  There is nothing inherently incorrect about the citations.  However, as Kenneth Myers from the University of Calgary points out, ""if research results are selectively chosen, a review has the potential to create a convincing argument for a faulty hypothesis. Improper correlation or extrapolation of data can result in dangerously flawed conclusions."  This couldn't be any more relative towards Cary Edgar's POPTS viewpoint  (he is founder of Ancillary Care Solutions which works with physician groups on in-house physical therapy).

While the smoking study only made improper correlations, the Advance article provides  major inaccuracies.  The most obvious one is the major point of their contention-the 2005 Medpac report which reports on physical therapy spending per patient in a variety of ways to include practice setting.  The data reported in the 2005 report is for the year 2000, not 2005 as he cites but let's not let the facts get in the way of improper correlation.  Even if the data weren't eleven years old (no shortage of POPTS proliferation during this time), the "spending per patient of $653 in private PT practices, and only $405 in physician groups" is like saying the increased lung capacity of a COPD patient provides an advantage in an ultra marathon.  To be fair, it is probably difficult for an attorney to realize that there are major differences between patients seen in an orthopedic POPTS clinic vs. a freestanding private practice relative to acuity or routines including the "one visit only home program or DME only visits cause the patient lives far away" syndrome that is commonplace.  Of course, there are tons of anecdotes of patients self-discharging because of the cattle call or inconvenience of the POPTS clinic resulting in a lower per episode cost but let's not even go there.  Furthermore, medicare's data in private PT practices includes many POPTS who have obtained medicare numbers and re-assignment of their PT's.  The bottom line is that medicare's own data doesn't unfortunately fully discern between POPTS and non-POPTS.

As to the claim that APTA is  misrepresenting conflict of interest.   Are you kidding?  The major issue of inherent conflict of interest via self-referral is not cost per episode but in excess referring of patients that don't need the service. There are a plethora of studies that show the problems of referring to entities that a physician owns including this recent one from a few days ago which show there is a different threshold for referral where there are financial incentives.  By the way, if you are going to reference Medpac reports, why wouldn't you provide the one from June 2010 as highlighted in this blog which includes the following quotes:

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

"There is evidence that physician investment in ancillary services leads to higher volumes 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"

 

APTA's white paper on POPTS was written in 2005 prior to 2010 Medpac and the significant number of published imaging studies which continue to demonstrate self-referral problems.  APTA shouldn't be attacked for this paper, they should be applauded as the evidence since then is more than just a little compelling.  Perhaps my favorite part of the viewpoint is the contention that " APTA's promotion of autonomous private therapy practices has almost undoubtedly resulted in lower payment rates for physical therapy services".    While I completely agree that payment rates for services have been unfortunately lowered, this is mostly due to PT's who sign the contracts and their inability to have any leverage in contract negotiations-something we can't put on the shoulders of APTA.

As to common ground, there is one area that I completely agree with the author:

"While the APTA and its state chapters have devoted a tremendous amount of time, energy and money in their decades' long campaign against POPTS and therapists that work for POPTS, they have apparently not conducted or sponsored any studies seeking to validate their allegations that physician-owned PT results in overutilization and unnecessary cost. Instead, as discussed above, the APTA has chosen to cite outdated and misleading studies that support its position and ignore findings that do not support its position."

 

However, as this blog pointed out a few months ago, the time has come. It would be a little disingenuous for APTA to do its own study on POPTS. This is the role of the independent  Foundation for Physical Therapy (full disclosure, I am a Trustee) and this exact study has been approved pending funding which is why APTA, Private Practice Section of APTA (in a major way), and others are stepping up to earmark a donation to the Foundation.  I believe the results will settle this argument once and for all.  How about it Ancillary Care Solutions?  Put your money where your viewpoint is and send some research dollars to the Foundation (you can even do it online).

larry@physicaltherapist.com

Introducing the Physical Therapy Business Alliance (PTBA)

It is with great pleasure that I introduce to you the Physical Therapy Business Alliance (PTBA).  If you have been reading this blog for any length of time, you will recall a request to participate in a Physical Therapy Practice Sustainability and Representation Survey. The survey resulted in over 800 respondents and clear, constant issues and messages . After a series of phone conferences, a dedicated group of private practice owners started to convene more formally to determine the feasibility of a trade organization focused on business issues of the profession, most notably the prevailing concerns of decreased reimbursement, regulatory constraints, and lack of a consumer message that private practice physical therapist businesses undoubtedly represents the best value in healthcare.  It became aware that many nascent groups were forming in various geographical areas across in regions or in some cases statewide where they were expressing similar concerns, thus a forum was needed to exist to assist, amplify, and communicate those initiatives.  Many of these "occupy" efforts across the U.S. have been done outside of traditional component and special interest group channels.  


After several meetings including legal consultation, strategic planning, executive and board development, and a full time administrator, PTBA was launched.  PTBA is now executing on our strategic plan and launching our general membership campaign.   A few month's back, PTBA began a soft, non-public launch of raising members via Founder's Circle invitations.  To date, we already represent 240 business locations, more than 730 physical therapists and 1,600 employees nationwide.  We have been transparent in communicating with APTA and in particular the Private Practice Section of which we so ardently support and (all BOD's of PTBA are required to be members of PPS) and we have some unconventional cooperative initiatives in planning stages with them.  As an organization of businesses (ATPA and its components such as PPS are individual memberships), we believe that many strategic alliances could be formed between PTBA and other PT related professional associations and stakeholder groups.

Although we have made a number of strides in recent years towards a more contemporary recognition of the role that physical therapists should play in healthcare, we don't believe the pace has been fast enough. Convinced that unbridled "GSD (get stuff done)" activism will generate tangible results quickly, PTBA's commitment is to be an agile organization built on a foundation of measured risk taking and motivated action.

As an example, we have demonstrated proof of concept in several key areas:

We can mobilize effectively
We can get legislation passed
We can leverage success of PT businesses to fuel success in other states
We can communicate rapidly efforts that are going on with external agents like OrthoNuts that are strangling business flow

These successes were achieved in collaboration amongst components, committees, PPS members and PTBA founders.  Results happen when we rally around the right idea, become unchained from stifling process, work collaboratively based on our collective strengths and influence, utilize innovative and "edgy" tactics, and motivate action without fear.

In short, PTBA exists to:

1. Be an ORGANIZATION of businesses.  There are many opportunities for organizations of "people" within our profession (sections, components, etc) but there is a void of business representation.
2. Be a PLATFORM to harness the power the power and awareness of local, grassroots efforts.   We will be a repository and broadcast through social media channels.
3. FOCUS on deliverables necessary for economic and clinical success of independent PT practices  (you will not see sales of branded capri shorts)
4. Create and leverage winning STRATEGIES.

If you want to be part of this movement, we invite you to obtain more information and and more importantly, JOIN. We need you.

PTBA Board Members

larry@physicaltherapist.com

john@texpts.com

My name is Dr. Joe Fabitz and I am your #physicaltherapist

How does that introduction or the nurse who uses a similar approach in this NY Times article possibly confuse the patient?  Only your doctor knows.

@physicaltherapy

#Physicaltherapist Pet Peeve #1

In the next several posts, I am going to outline my biggest professional pet peeves.   #1 is easy, I hate the term skilled physical therapy and even the term "physical therapy" is starting to be an irritant.

The origin of this debacle stems from medicare's language and the requirement in the certification portion of the plan of care (which in and of itself is also a major pet peeve) that requires that the medical needs of the patient are such that they require"skilled" services.  The intent is to differentiate that the services are not maintenance.  Oddly enough, there is legitimate debate and legal work which is defending the rational for providing maintenance services to medicare patients because it prevents downstream problems and costs but that's another post for another time.  Unfortunately, within our own profession  "skilled physical therapy" has taken on a life of its own.

The rational is that if a non physical therapist (e.g. technician) is performing a service under direct supervision of a PT that the service is not "skilled" and therefore it is not physical therapy and therefore should not be reimbursed.   Medicare took this too an extreme and released an explicit provider list that requires all services be performed by a physical therapist or a physical therapist assistant.  Many within our own profession and even within our national association have tried to make this the standard.  The famous RC-3 which passed overwhelmingly is one step to unravel that mess.  We can only hope that somebody at CMS applies a more logical stance to their hypocritical rule.

CMS has extensive language about PT's and PTA's.  It aptly defines a physical therapist and even refers to their scope of authority "in accordance with state laws".  CMS also define's clinician "to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel)". Understandably, the definition of a clinician does not include physical therapy assistants.  So the first question you have to ask is why in their explicit provider rule do they include a clinician and a non-clinician? Why doesn't it include other non clinicians who while under direct supervision of a physical therapist are allowed under most state practice acts?  Perhaps more to the point, CMS states that 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."   Therefore, are we to believe that "skilled physical therapy" is provided by a non clinician who cannot provide clinical judgement?  Which brings me back full circle to the whole pet peeve of "skilled physical therapy". (side note: don't kill the messenger here, I am only reporting CMS' own language).

If we use the term "physical therapist's care" there is clearly an impression of skill, clinical judgement, licensure, clinician, and authority.  We have made the term "physical therapy" so generic that its meaning is ambiguous and it has become an interchangeable part for non clinicians like physical therapy assistants, ATC's, techs, personal trainers,  and exercise physiologists (whoever they are).  Attaching the term "skilled" in front of it has made it more marginalized since it is literally care by a non-clinician who cannot make clinical judgements.  Yet, we even have a large faction saying that it the care even if under direct supervision of a PT is rendered by other non-clinicians who cannot provide clinical judgements it is not skilled therefore it cannot be reimbursed. Sound absurd? You bet.

There is an antidote.  Let's get rid of the term physical therapy when the context should be physical therapist or care by a physical therapist.  The implication of physical therapist's care would always paint the responsibility of the patient to their PT who is liable.  This is very similar to physicians who clearly are responsible for the patients care regardless of who took the blood pressure, temperature, or filled the syringe with medication.   When we use the term physical therapy it is unfair to the educational rigor and knowledge attainment by the professional responsible.  The emotional argument about restricting delegation and direction of care by the physical therapist is always based on a perceived notion of abuse and a perverse incentive to use only technicians for financial reasons.  Can't we agree that there already exists lots of abuse by over using non clinicians who cannot provide medical judgement doing physical therapy including physical therapy assistants who practice without on-sight direction and supervision?  Can't we create a cultural shift via a re-branding effort to always point to the physical therapist as the lynchpin?  isn't that what a 7 year doctoring profession and vision 2020 is all about?

I know that I am going to try my best to promote in this manner.  We market heavily and promote that patients have their own personal or family physical therapist.  Rory Mcilroy who hurt his wrist in a recent golf tournament had his personal "physio" come out and take a look. Heck, even Cher recently sent her physical therapist to to take care of her son who injured his knee on Dancing with the Stars.

Wouldn't a name change to American Physical Therapist Association make more sense? Just doing a small part and changing to hash tag #physicaltherapist is a small step in the right direction.  Lastly, this post is in no way intended to denigrate physical therapy assistants and other non clinicians who clearly play an integral role in a physical therapist's care of a patient.

Thoughts?

@physicaltherapy (trying to change to @physicaltherapist)

Letter from #Physicaltherapy Board of California to PT's working for MD's

The following letter from the Physical Therapy Board in California is apparently on its way to PT's working illegally as employees in physician offices.  This issue has been covered extensively.

 

Dear PT:

 

The Physical Therapy Board of California (Board) recently became aware that the employment of physical therapists in a medical corporation, formed under the Moscone-Knox Professional Corporations Act, is a violation of Corporations Code section 13401.5.  This new understanding has prompted creating the enclosed Summary of Facts Related to the Practice of Physical Therapy by Corporations, and mailing of this letter, to ensure licensees regulated by the Board are also informed of this provision of law.  Additionally, the Board has recognized as a separate issue, some physical therapy corporations organized as general corporations are not in compliance with the obligation imposed on all corporations providing professional services by Moscone-Knox, which may also create employment issues for professional employees of these corporations.

The Physical Therapy Practice Act (Act) was enacted by the legislature in 1953.  The Act created the Physical Therapy Board of California [then the Physical Therapy Examining Committee] in Business and Professions Code (B&P Code) section 2600, - of that chapter;- B&P Code §2602.1 of the Act; states, “Protection of the public shall be the highest priority for the Physical Therapy Board of California in exercising its licensing, regulatory, and disciplinary functions.  Whenever the protection of the public is inconsistent with other interest sought to be promoted, the protection of the public shall be paramount.”

The mandate of the legislature is to enact laws.  It is the mandate of the Board to enforce the laws enacted by the legislature.  As a result, the Board must enforce Corporations Code section 13401.5 which excludes physical therapists as one of the professions authorized to be a shareholder, officer, director or employee of a medical corporation.  The Board’s directive is supported by the two legal opinions enclosed with this letter, 1) September 29, 2010 California Legislative Counsel Opinion; and, 2) Legal opinion issued by the legal office of the Department of Consumer Affairs on February 28, 2011.  Furthermore, the Board must ensure all corporations offering physical therapy services, as well as all PTBC licensees employed by such corporations, are in compliance with applicable provisions of Moscone-Knox.

This letter and the enclosed Summary of Facts Related to the Practice of Physical Therapy by Corporations are intended to ensure licensees are knowledgeable of this recent clarification of the law and to aide in making informed decisions regarding employment. Receipt of this letter should not be taken as indication the Board is currently investigating you or your license; or, is currently planning enforcement action against you or your license.  Nevertheless, each recipient of this letter should be aware the Board has received a complaint pertaining to his/her employment situation and are advised to thoroughly review this material.

If after reviewing the enclosed information, you find you are in an unlawful employment arrangement and require time to come into compliance please notify the Board by September 1, 2011 of your compliance plan.  Since it is not the intent of the Board for licensees to be unemployed, or the public’s access to healthcare professionals to be limited, the Board will consider each plan submitted and will authorize time for implementation of any plan deemed to be reasonable. However, you should be aware; it you are unlawfully employed and do not respond with a plan of compliance, it will constitute cause for enforcement action.

Please do not hesitate to contact the Board office if you have any questions or concerns regarding employment and compliance with section 13402.5 of the Corporations Code and the Board’s obligation to enforce the law; however, be aware the Board and its staff cannot provide you with legal advice and will not be able to create your compliance plan for you.  The Board hopes you find this informative; and, if necessary, gives you the opportunity to come into compliance with the law.

Sincerely,

Physical Therapy Board of California

 

Third Story on California POPTS #physicaltherapy Bill

Found here.  Keep the comments going.  AB783 even has its own twitter account!

 

 

Patient Choice, Patient Access to Physical Therapy, and the Free Market

This year, state legislation aimed at improving patient access to skilled physical therapy services has been introduced in Tennessee, Texas, California, and Michigan.  All of these bills would enhance patient choice and access to treatment alternatives to surgery and medications for movement dysfunction and mechanical pain.

 

These pieces of legislation are being met with resistance from the medical community including orthopedic groups and state medical associations.  These groups perceive direct access to physical therapy as a threat to their financial stake in managing patients with mechanical pain. The primary rationale for opposing patient access to physical therapy is based on the view that this extension of services for outpatient PT without physician involvement would lead to increased utilization of medical services and therefore would increase costs to insurers and their beneficiaries.

 

This is a view is completely unfounded and is not supported by the evidence from countries in which there is a mature direct access base for physical therapy.  In fact, the current evidence demonstrates the opposite—where there is more imaging there will be more surgeries and greater disability rates.  See HERE and HERE and HERE.

 

The rate of back surgery in the United States is approximately 40% higher than in any other country and more than five times those in England and Scotland. Back surgery rates increase almost linearly with the per capita supply of orthopedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy.

 

The truth is, if the current system of physician referral for orthopedic interventions was working well and the system was coping with the current utilization, there would not be a problem and increased scrutiny toward orthopedic groups who employ their own physical therapists by MedPAC and the media. 

 

Direct access for physical therapy will only be of benefit to the general community if this system works cost efficiently and there is perceived to be incremental value in self-referred treatment pathways to PT.

 

If a patient is self-referred for rehabilitation and does not perceive value or benefit, they will not be compliant or continue treatment. Likewise, self-referred patients to physical therapists tend to be more motivated and require less treatment than physician referred patients.

 

In a mature patient direct access (to PT) market for musculoskeletal pain, where people in pain truly have a choice as to where they receive treatment, they will go where the product, and therefore the outcomes, are the best.

 

Internal medicine referral patterns to orthopedic surgeons for musculoskeletal pain has led to an overwhelming increase in imaging services, pain medication prescription and surgeries and the clinical outcomes have not improved and according to some has declined in recent years. Many orthopedic groups own their imaging equipment and also have their own PT departments and thus benefit financially from physician referral to their own facility. 

 

While the general community has grown cynical of costly and inefficient referral practices, it is also tired and disillusioned with ordinary and ineffectual physical therapy services. Patients are more and more looking to alternative treatment paradigms. The traditional exercise based physical therapy where a PT is required to perform an evaluation but often transfers the oversight of the treatment to an ATC or technical assistant will not wash in a mature direct access market.

 

That is the point.  In a mature direct access market, where a patient seeks the care of a physical therapist directly, only excellent physical therapy will thrive.  Physical therapy will get better and more efficient in a mature direct access market as the poor rehabilitation will fail to thrive.

 

When profit form referral motives are removed and there is truly a choice in where to receive treatment for musculoskeletal pain, people will not return and will not refer others to inferior options. Direct access will level the playing field and thus shift the power to the health care consumer where competition drives innovation, value, and clinical excellence—not the halo effect associated with cozy physician relationship based referrals.

 

If orthopedic surgeons can no longer benefit financially from self-referral, they will send to the best quality PT at their disposal and they will quickly learn who is delivering the outcomes they require in the rehab of their patients.

 

Similarly, part of being an excellent physical therapist and one who will thrive in a direct access market, is being an expert in differential diagnosis, and one who recognizes when a patient will benefit from referral for an orthopedic or neurosurgical consultation or alternative opinion. Direct access physical therapy must be good enough to know what is not responding within a reasonable timeframe and recognize early when some diagnoses need to be cleared before conservative rehab begins. This delivers value to the system, not cost.

 

Two weeks of conservative management is more cost-effective than MRI for most conditions as long as there has been a full and thorough clinical evaluation to clear more significant pathology.  This plays into the physical examination skills of the licensed physical therapist.

 

Direct access will gather momentum and the general community will benefit incrementally from the process, but physical therapy has to be good enough to become the gatekeepers for musculoskeletal pain.  Current physical therapy (PT) education mandates that these skills are taught in the entry-level curriculum, but obstructive laws prohibiting patient access to quality PT limits practice of these learned skills.  As in any market, the best will prevail and the rest will dwindle. We owe it to ourselves as a profession to promote patient direct access and be held responsible and accountable for the musculoskeletal wellbeing of our patients.  The medical profession isn’t meeting this need.

 

C. Jason Richardson, PT

Greg Spurgin, PT

Accountability in #physicaltherapy RC 03-11

Roughly one year ago, we had 2 blog posts here and here regarding RC 15-10  that the Private Practice Section was moving forward to the 2010 House of Delegates.  For a variety of reasons, the RC was withdrawn. The good news that it is back as RC-03-11.   

I have taken the liberty to edit that post and have pasted it below with the addition of a few additional arguments that have materialized-most notably the lack of trust that PT's have for each other.

Our national association espouses PT’s to be autonomous practitioners in its vision 2020 statement.  At the same time, it maintains positions that restrict PT’s ability to practice within their scope of practice.  These positions are then represented to third parties-including medicare and other payors in a variety of ways including insurance conferences.  Left unchecked, medicare’s restrictive and oppressive rules might just metastasize as standard.  Fortunately, the Private Practice Section is attempting to reconcile it by virtue of a motion to the House of Delegates: RC 03-11 Physical Therapist Accountability for the Delivery of Care.  Unlike last year's RC 15-10, the Section met with representatives of many other sections in order to craft a more comprehensive RC and support statement including multiple RC's that if relative (depends on whether RC 03-11 passes), essentially affirm the position that "physical therapy is exclusively provided by a physical therapist".  

For reasons that historically are unknown to anybody out in the trenches actually seeing patients, APTA has the following positions:

• APTA’s position Direction and Supervision of the Physical Therapist Assistant (HOD 06-05-18-26) states:

 

The physical therapist assistant is the only individual permitted to assist a physical therapist in selected interventions under the direction and supervision of a physical therapist.

 

• In addition, the House of Delegates has also addressed payment for physical therapy services through the position Reimbursement for Physical Therapy Services (HOD 06-01-12-15) that states:

 

The patient/client management element of interventions should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant performing selected interventions under the direction and supervision of a physical therapist in accordance with the American Physical Therapy Association policies, positions, guidelines, standards and Code of Ethics.

The problem of course is that these positions fly in the face of the overwhelming majority of states and the model practice act which states the following:

• The Federation of States Boards of Physical Therapy (FSBPT) in its Model Practice Act defines two individuals involved as care extenders in the practice of physical therapy, the physical therapist assistant and the physical therapy aide.  The Model Practice Act defines these two care extenders as follows:

“Physical therapist assistant” means a person who is [certified/licensed] pursuant to this act and who assists the physical therapist in selected components of the physical therapy treatment  intervention.                                                                                                                                                                  “Physical therapy aide” means a person trained under the direction of a physical therapist who performs designated and supervised routine tasks related to physical therapy services.”

Thanks to leadership within PPS, the RC efforts seeks to remove these baseless positions.  While thankfully there are currently only a  few private payors restrict practicing PT’s to anything other than primarily their licensure-as it should be-this seems to be lost on an organization that is clearly disconnected from the day to day practicing PT on this most important issue.  Unfortunately, the largest payor-Medicare has adopted their completely unjustified position-much to every practice’s dismay which has done nothing but run up cost to practices and placed the focus on external compliance rather than patient care.  Isn’t it a little ironic that in times to try and meet growing demand with less resources that we are restricting practice rather than trying to expand our scope like most other medical professionals?

For the “ insulated idealist PT’s” (and background post) out there that disagree, the primary defense goes along these lines:

-you only want to use techs for financial gain-this RC is only about "MONEY"

-how can you represent anything a tech does as “physical therapy”?

-if we have that position than all MD’s will do is hire techs

-patients are already confused about who their PT is, utilizing techs will add to this confusion

-such a position would increase the amount of fraud in physical therapy

-payors will pay less knowing that you are using techs

-we will have to change all sorts of documents at the national level if we change this position

-how can we trust PT's to actually make the right judgements regarding use of extenders?

let’s rebut these one at a time.

-you only want to use techs for financial gain-this RC is about "MONEY"

The primary reason that PT’s ought to be able to delegate and direct support personnel has nothing to do with financial gain but everything to do with their training, judgment, and scope of practice.  A PT autonomous provider has the necessary education and this is supported by the majority of  practice acts and the model practice act.  It is almost hard to believe that a national organization would not be in support of the model practice act but that is an entirely a blog post of a different time.  I have personally looked at 3 different non physician medical professions and the positions of their national organization.  There isn’t one that attempts to superimpose, restrict, or eradicate their professionals scope of practice.  Perhaps the best evidence that this position isn’t for financial gain is the liberal use of support staff by the US Military where reimbursement is not a concern and physical therapist’s have expanded scope of practice.  Of note, is the high percentage of board certified PT’s and the significant scholarly contribution to the body of physical therapy knowledge by PT’s in the military.  Few if any practices actually in practice take APTA’s position seriously other than for medicare patients where they are obliged.  Why have a position that the overwhelming number of PT’s in reality don’t abide by because their practice acts don’t restrict them in that way?  Lastly, why is it that in the debate of Direct Access for Medicare these folks don't claim that the issue is "MONEY".  Isn't direct access potentially a lot more financially oriented?

-how can you represent anything a tech does as “physical therapy”?  This isn't SKILLED physical therapy!

You don’t.  You only represent what a PT performs, directs, and delegates under supervision as a PT.  A PTA by definition (including CMS) cannot make clinical judgments nor changes in plan of care yet we have no issue representing their work under supervision of a PT as “physical therapy”.  A PT can easily make judgments about what tasks a PT tech can do as well.  "Skilled" physical therapy is a redundant and unnecessary term that was placed in the PT world by CMS who wanted to ensure that differential from "maintenance" and even that is being legally challenged. The skill of the PT is in their collective use of clinical decision making, examination, and hands on techniques.  All physical therapy is "skilled" and like all aspects of medicine certain tasks require higher level of skills than others (heart bypass takes more skill than doing a blood pressure).

-if we have that position than all MD’s will do is hire techs

The significant difference here is that nobody is advocating that the PT is not the sole source and responsibility of providing physical therapy.  Physicians who do not hire PT’s to provide physical therapy are clearly in violation of this principle.

-patients are already confused about who their PT is, utilizing techs will add to this confusion

When providers use multiple support personnel it is incumbent on them to clearly differentiate.  Do patients get confused between who is the doctor and who is the nurse?  Proper risk management is indicated so that confusion doesn’t occur under any scenario.

-such a position would increase the amount of fraud in physical therapy

Thankfully, few private payors have adopted the stifling national positions so rampant increase in fraud is unfounded.  In fact, if one looks clearly at the recent and well publicized fraud cases, there is clearly a malicious intent to tamper the rules.  We have to avoid dumbing down the rules in PT under the flawed assumption that all PT’s are crooks and incapable of decision making.  As we have detailed in this blog, fraud in physical therapy is almost always committed by those with a criminal, malicious intent-not the 99.99% of PT's who see patients everyday.

-payors will pay less under knowing that you are using techs

Perhaps somebody hasn’t realized that despite our national organizations attempt to restrict PT’s from practicing within their license that payors have already decreased reimbursement significantly.  The variables that determine what providers accept as payment are completely independent from what our national organization’s positions.  In fact, the representation of those positions has unfortunately worked on medicare causing the most disruptive of processes including scheduling exceptions to avoid overlaps and resources, additional monitoring costs, and a focus on hourly billing that results in a wage cap on physical therapist’s earnings.  Recent studies indicate that the most disengaged professions are those that work on a billable hour rate in an algorithmic fashion.  Is that what we want with such superimposed rule restrictions?  There are many PT’s who believe that nobody can treat a patient except a PT or a PTA.  Support of RC 03-11 will not prohibit them from practicing that way.  Side note: the states with that are the most regulated and most restricted from a practice act standpoint have the lowest reimbursement in the U.S.-sorry New York.  

-we will have to change all sorts of documents at the national level if we change this position

That’s just a shame isn’t it-progress does have a cost.  Let’s not do anything cause it will cause further edits and clarifications in support of a PT autonomous practitioner working within their scope of license.

-how can we trust PT's to actually make the right judgements regarding use of extenders?

This argument seems to be catching the most steam and one that I find the most amusing.  Out of one side of the mouth is an argument about how PT's can effectively and efficiently differentially diagnose a direct access patient but they cannot be trusted to make decisions on supervision!  Inpatient PT's can delegate on a vent dependent patient but outpatient PT's can't use an extender! 

I urge you to talk to your component’s delegation and voice your support for RC 03-11 Physical Therapist Accountability for the Delivery of Care.  It’s high time we have consistency in a PT’s license and outdated and unfounded positions from our national organization.

If you don’t know your delegation and aren’t a member of APTA, I encourage you to join by going here.  Just because I disagree with APTA on this significant issue doesn’t imply that I am anything but an ardent supporter and volunteer of our profession’s national organization.  It’s time to bring transparency and active debate to such a critical issue in our profession rather than leave it in the hands of those that quite honestly may not represent the PT’s in the trenches.

I look forward to the thoughts and debates on this.

larry@physicaltherapist.com

 

April #Physicaltherapy stuff

Barely into April, we see lots of interesting news items happening in our PT world:

Hypocrisy  Calif AMA Charlie Sheen wasn't the only piece of work out of California these past several weeks.  The debacle known as AB 783 stoppopts has taken an interesting twist.  Calif AMA is coming out in strong opposition of AB 1360 which in essence allows healthcare districts to directly hire physicians.  Why might you ask?  Cause of course this would allow hospitals undue influence on doctors  and would compromise care.  However, Calif AMA strongly supports what looks like a revised bill AB 824-per their argument "cleans" up language that doesn't allow PT's to be solely independent contractors and thus be rightfully employed in physician's corporations  where they of course would never be under the undue influence to compromise patient care.  This is almost as funny as their own physician testimony to the history of PT and their contention that we don't have our own professional association!

EIM "pinhead"  of the month Dr. Bert Apparently, even the Orthosupersite dropped his presentation gem which bragged amongst other things of putting "60% of PT's  in S Carolina out of business". Did they drop this because of the current Calif stopPOPTS or because we suggested in this blog that it could serve as a good foundation for restraint of trade lawsuit?

Congrats to Private Practice Section for timely response to ACO and their lobbying efforts including a member free upcoming webinar on ACO's as it relates to private practice.  I am even more confident in positions espoused on this site which can be found here and here.

Privatizing Medicare Completely There is now discussion based on budget proposals to completely get the government out of medicare and instead allocate dollars or vouchers to beneficiaries who would choose a private carrier.  While on the one hand this might get rid of CMS's superimposed rules, it might also end up looking like OrthoNuts for Seniors (side note: keep those appeals going as it is our only chance to rid their ability to prey on PT practices).

Strange but true While on spring break this past week, I got an email from somebody who wanted to by my @physicaltherapy.  No, not my twitter tag but my physicaltherapy name on the incredibly popular  "words with friends" game.  Maybe it was a California doc not wanting to unduly influence me?  I didn't sell!

Manipalooza 2011 While on spring break, I prepared my Manipalooza talk.  This is an EIM event taking place May 21-24 (full disclosure, I am a principle in EIM as if you didn't know but blog regulations make us do this).  The first half day (the only part where they let me in) are all provocative talks where each speaker is given no more than 20 minutes and must have a symbolic and representative song.  The balance of the festival is manual therapy and EBP ad nauseam.  I will try and make a compelling argument that for patients and for the overall good of healthcare reform that PT's are THE Positive Deviants and my song is Backstreets by the boss.  Here is some more information including presentations from last year (and Robbie-Rob's Rap).  Hope to see you there.

larry@physicaltherapist.com

@physicaltherapy both twitter and "words with friends"