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Are we good enough?

The military health care system is not always perceived as being the most innovative, but I will confess to being quite impressed with the plenary remarks given by the Army’s new Surgeon General, LTG Patricia Horoho, at the 2012 Military Health System Conference, which was hosted this past week at the Gaylord Convention Center, National Harbor, MD.

Even her slides deviated from the typical military style “cram everything into a single slide” presentation and focused on key, memorable facts to support her position that we spend far too much time and resources in health care focusing on the 1% (when you’re actually sick and visiting a health care facility) and not nearly enough on the 99%, which is the rest of the continuum of health.

Here is the link to the talk, which begins on slide 28. You have to get through 10-15 slides on some military specific stuff before the portion that I am alluding to begins on slide 48. The majority from here on is highly relevant for the vision of the broader health care system. It’s a brief talk, so I am hoping you might have the chance to view while sipping on your Sunday morning coffee. Enjoy!

John

Thurst Manipulation of the Cervical Spine: To Do or Not to Do

There has been some recent email traffic amongst a close group of colleagues on this article recently published in JOSPT. You can read the study for yourself, but the gist is that the combination of upper cervical and upper thoracic high velocity thrust manipulation was more effective in the short term (48 hours) than nonthrust mobilization in patients with mechanical neck pain. The question centers around whether and/or how to incorporate this evidence into practice. Rather than offering a summary of the comments, I thought it would be helpful to simply paste the comments verbatim and then open it up for a conversation on the blog. I did do some editorial clean up of syntax, grammar, etc. I left names off because I didn’t get permission to include their comments. However, these are each thought leaders in their own right who generally don’t mind expressing themselves so I am taking a risk that they won’t mind. I did remove comments that could be linked back to a specific individual. Other than these exceptions, the comments are verbatim.

Comment 1
This is an area that I have struggled with for years. Currently I do not teach upper cervical manipulation to the entry level students. I have taught upper cervical manip to entry level students in the past, but I don't think they can control their hands enough to do it safely. Now one could argue that the manip James Dunning used in this study might be safer than some of the other upper cervical manips that involve rotation (ala Gibbons and Tehan), but I still don't think entry level students can learn this properly in the time we have to teach it. I do teach middle and lower cervical manipulations and they do ok with it. I do not think upper cervical spine manipulation is an entry level skill, and, one could argue, that cervical manipulation in general should not be taught until there is more evidence. I do use upper cervical manipulation a lot in my patient care and find it extremely useful, but I treat a young, healthy population (college students) and do a lot of screening.

Comment 2
I don't have much to add except that it would be interesting to see what the longer term outcome looked like. I am curious why they didn't report at least a discharge time frame outcome like 4-6 weeks. Obviously even longer term would be better. Presuming there are no differences at 4-6 weeks, I am not sure the outcome is worth even a small risk (real or perceived), especially if some of the patients were acute, the stage in which a stroke might naturally occur regardless of a manipulative intervention.

Comment 3
I don’t have a lot more to say but agree that the students don’t have enough feel or clinical knowledge to perform upper cervical manips. I certainly don’t teach it to them. They can do very well using MET and Mobs. Actually, even though the study in question uses cervical manips, there are others out that say mobs and manips are of similar benefit in the cervical spine. So, again the discussion of risk benefit is appropriate. I won’t shy away from having the students read the article, but I don’t think that is what I would want to project. A healthy discussion following is a good idea.

Comment 4
Agree with the only clarification being that upper cervical manip is a motor skill that can be learned by entry-level students if there were enough time and there was a definitive benefit that justified the resources for packing it in and teaching it. Given the current structure there isn't. That having been said, it very well may be that this is something Interns can learn after they have been in the clinic for a while, performance has been assessed, and the CI can give adequate time to teaching this to Interns who would have developed more skilled hands. I think we just need to be consistent in our philosophy about teaching manipulation. It isn't about 1st professional or "experienced" (there are a lot of those I wouldn't teach either). It’s about time, resources, and priorities based on evidence (harm/benefit).

Comment 5
Framing this is important.

1. I do not specifically teach thrust manipulation of the upper cervical spine to entry level nor do I advocate it for post professional at least without a serious dose of respect to this area.

2. As evidence emerges, this may change. So, it is in within the scope of practice of entry level PT as are PNF techniques. However, a student may or may not learn all the PNF or manipulative skills. So we need to be very clear that it is within the scope but caution is warranted.

3. I treat an older population and am less nervous about them in terms of a VBI stroke (carotid different picture). I actually am much more cautious in our student labs because that group is at higher risk for a VBI stroke than my crusty old folks. Now I am more aware of BP, HR, overall stroke risk, etc in my older adults but much more concerned about treating younger adults, particularly “loose neck” females.

Hopefully this is enough to get a decent conversation going on the blog regarding whether you agree or disagree. Before commenting, do try and review at lease the abstract of the study as it will likely help inform your thoughts and comments. Hope everyone has a great weekend!

John

Spinal Fusion Rates Continue to Climb

This article from Medscape came across my radar a few days ago, and a number of colleagues had some interesting email dialogue around it (Britt, thanks for initiating the discussion!). The gist of the conclusion is that between 1998 and 2008, the annual number of spinal fusion discharges increased 2.4-fold (137%) from 174,223 to 413,171. In contrast, during the same time period, laminectomy, hip replacement, knee arthroplasty, and percutaneous coronary angioplasty yielded relative increases of only 11.3%, 49.1%, 126.8%, and 38.8% in discharges, while coronary artery bypass graft (CABG) experienced a decrease of 40.1%.

A few points worth considering. First of all, TKA is a close second in growth rate, so clearly there are other surgical procedures that might rival spinal fusion surgery for the “over utilization of the year” award. It would also be interesting to know the percentage growth of spine surgeons compared to other specialties during this same period. In other words, is the rate of increased utilization commensurate with the rate of training spine surgeons? What is definitely clear is that the increased utilization of spine fusion is not commensurate with increasing evidence to support it because none (or very little) exists, especially for chronic pain, which is unfortunately an all too common indication being used to justify doing the procedure.

If you remember our infamous “Whore of the Month” series from a few years ago (George, no worries…we won’t bring it back!), I am afraid spine surgeons (not all of them but certainly the ones doing lots of unnecessary fusion surgeries) might be our first lifetime member because of the frequency with which “bad news” emerges with respect to spine fusion.

I suppose that for the sake of patients with chronic back pain looking for a cure (and willing to be exposed to high risk procedures that offer very little hope for benefit), we can only hope that spinal fusion surgery might soon go the way of coronary artery bypass graft, which is down! As Barb Stevens said in our email dialogue, we should expect to see PT become the safer, less expensive, and more effective alternative to spine surgery just as stents have been to CABG.

What say you?

John

We Can Do Better than a ‘Hope and Prayer’ Strategy for Clinical Education in Physical Therapist Academic Programs

Below is the text from a talk I recently gave via Skype at the PPS Graham Session this weekend in Charleston, SC. I unfortunately was unable to attend due to a last minute military deployment. Many thanks to Steve Anderson and the Graham meeting participants (and as I understand it, was record attendance and a terrific meeting) for allowing me to be there virtually via Skype to deliver my talk. As always, it's a genuine privilege to be in the same room (whether face-to-face or virtually) with friends and colleagues who are members of the greatest profession on Earth.

John

Delivered via Skype on Saturday, Jan 14 at the recent PPS Graham Session in Charleston, SC
Despite positive reforms in physical therapy education in recent years including the transition to a doctoral level education, clinical education has lagged. Physical therapy clinical education remains a highly fragmented and ill equipped system, marked by an inefficient 1:1 student to instructor format consisting of several short duration clinical affiliations, which leads to disjointed, highly variable, and non-collaborative learning. If we are going to be a meaningful contributor to health care reform and more importantly, play a prominent role in the reform process, we must hurriedly wake up from our delusions of grandeur, embrace the fact that we have a deep chasm in clinical education that must be closed, and wholeheartedly distance ourselves from the status quo.

The current physical therapy clinical education system leans heavily on a ‘barter arrangement’ completely dependent on the altruism of clinical practices at the sheer mercy of the academic program. For example, the short duration of the average clinical affiliation combined with the Interns’ limited skill set mitigates their potential to become a productive, value added member of the staff. Clinical resources are inefficiently expended to help the Interns learn the various systems, documentation standards, billing procedures, etc., only to have the student move on to their next clinical affiliation immediately after their useful assimilation into the practice. In short, the indirect costs for clinical practices to provide clinical education under the current model are steep and bothersome. Other than altruism, it is curious how academic programs have been successful in affiliating with clinical practices at all. Yet, in our typical peace gene like fashion, we oblige the “predatory” behaviors of academic programs who have duped us into believing that it is our professional duty to provide free clinical education for students while the academic program rakes in substantial tuition dollars during clinical affiliation semesters for which the academic program provides virtually no services!

Before I offend those of you in the audience who are on faculty in an academic program (ok, I probably already have!:)), think about this with me for a moment in practical terms. As educators in entry-level academic programs, we sit in many a faculty meeting debating the pedagogical pros and cons of adding “ABC” content, taking away “DEF” content, dedicating more time to topic “X”, less time to topic “Y”, etc. In fact, many of our curricular “experts” even get passionately defensive when making such arguments. You should see some of the heated debates that ensue when it comes to determining what content should be included in the didactic phase of physical therapy education! As a result, our students tend to progress through a highly organized and systematic curricula during this phase, evidence by a detailed schedule and syllabus. Nothing is left to chance. For example, it’s no mystery to the student as to what books they need to buy, what time they need to be where for what class, and what content to review prior to each class. We diligently measure student performance through countless rigorous written and practical exams. What strikes me as most odd then is why we don’t appear to be bothered by the lack of a clinical education curriculum that you can "touch and feel". For example, can a single DCE in the country tell me what content their students are learning on week 4 of their clinical education experience? How about week 18? What about week 23? Unfortunately, the default strategy for clinical education hinges on a “hope and prayer” strategy in which we send our students out into widely disparate learning experiences with little to no connectivity between clinical sites or even to the academic program. We then sit back and “hope and pray” that our students have a good experience. Think about the lunacy of our current 1:1 model with me for just a moment. Even the most highly capable clinical faculty do not have the depth and breadth of knowledge and experience necessary for a comprehensive clinical education experience. By the way, if we are to achieve meaningful reform in clinical education, clinical faculty must have the same faculty status and privileges of full time core faculty, if not higher!

Complicating matters, there are only 3 prerequisites for qualifying as a clinical instructor in our current model. First, you must have a PT license. Second, you must have a heart rate and pulse. Third and final, you must not be in a coma. If you meet these 3 criteria, you will be inundated with requests from DCEs around the country to affiliate with their program. Lest you doubt me, just ask any DCE how many contracts he or she attempts to manage under the current system. Most will answer somewhere between 250-500 contracts, yet the program is only able to assign 1 or 2 students each year per location in most cases. Therefore, the DCE inefficiently spends countless hours managing affiliation agreements with practices that take very few students in aggregate over time. As a result, the clinical education sites are rarely connected to each other in an organized way and frequently even remain at an arm's length from the academic program, tethered only by the clinical affiliation agreement. You don’t have to be an ISO 5000 certified quality engineer to understand that quality assurance across this many educational experiences is impossible.

Fundamentally, the potential transformation of physical therapy clinical education is dependent upon the ability of academic institutions and clinical practices to align themselves in a symbiotic relationship that delivers mutual benefit and value for all stakeholders. The medical model of clinical education has long proven useful in the training of residency-trained physicians. Interns would train collaboratively in group settings rather than a far more narrow learning experience that occurs when you only have 1 clinical faculty member. We should foster the development and evaluation of a standardized internship curriculum that leverages online learning management systems and team-based learning to deliver a consistent learning experience regardless of location. In other words, we need to “crowd source” clinical education so that the full “universe” of knowledge is available to them, not an isolated slice. One could even envision a matching process whereby students are competitively matched to specific residency programs…the right student to the right clinical education experience at the right time, the results of which would further incentivize quality and standardization and create a win/win/win proposition for students, educational programs, clinical practices, and most importantly, the patients to whom we provide care.

Finally, it’s an outrage that our graduates currently have debt that is completely out of proportion with their ability to recoup their investment. As it currently stands, there is no compelling economic argument to pursue a career as a physical therapist because of the inability to achieve a return on investment that justifies the necessary debt burden of the average student. Unfortunately, academic programs are in a negative incentive situation when it comes to such reform because students currently pay tuition to their academic institution while completing their clinical rotations, creating a veritable cash cow for the academic program, yet the academic program provides few services during this period. In fact, I routinely advise students that when their DCE calls them during their clinical affiliation to check in on how things are going, they should make the DCE stay on the phone for at least 100 hours to even begin recouping the value of the investment of tuition dollars the students have poured into the program.

We must disruptively innovate within clinical education to attract the best applicants into our profession, many of whom currently pursue careers in medicine instead. Similar to the medical model, students should attend physical therapy academic programs for didactic learning experiences, graduate once that component is finished, sit for licensure, and immediately begin a formal internship/residency lasting a minimum of 1 year. Interns would receive a modest stipend in exchange for receiving a high quality standardized training program delivered under the auspices of a credentialed graduate medical education system that adheres to rigorous accreditation and quality standards. Migrating the preponderance of clinical education to the post professional, post licensure setting would shorten the typical academic program by 1/3 (2 years rather than 3), trimming tuition accordingly.

In summary, we can no longer justify clinical education being relegated to 2nd class citizen status, and surely such a low view is inadequate for the contemporary Vision 2020 physical therapist. We are starting to see some innovative internship models emerging, such as those at the University of Pittsburgh, MGH Institute of Health Professions, the US Army-Baylor Doctoral Program in Physical Therapy, and Rocky Mountain University, among others. However, the rate at which the transformation is happening is far too slow. Fundamental reform of clinical education is critical for guiding the future of physical therapist education, and the immediate possibilities for such reform are real and tangible. In doing so, clinical education can be transformed into a collaborative and highly effective experience that will serve to elevate the role of the physical therapist in our health care system. Disruptive innovation is needed…and needed fast!

A Blast from the Past

I received this interesting email below from Richard Don Tigny, whose views on the SI joint bring back memories of the 1980s and 90s...way out of touch with reality. Nevertheless, I thought his comments were instructive on a couple of points. First, if we are to become an evidence-based profession, we have to learn to respond in a timeframe faster than 5-6 years. He is apparently responding to some critical comments I made back in 2007 regarding his views being inconsistent with current evidence (view which are even further away still in 2012).

Also, before you criticize me for posting what was intended as a private email on a blog, I did ask for and receive his permission to post his comments here, which brings me to my second point. Some individuals don't mind sharing their lunacy with the entire world, which reminds me of a quote by Epictetus who said, "We have two ears and one mouth so that we can listen twice as much as we speak." In all seriousness, and with no intent to make this a personal attack, it's helpful to realize that there are a few who still cling to views that are completely out of step with current best evidence. Although I hesitated to even post his viewpoints because doing so might give them more credibility than they're worth, it's sometimes instructive to see a stark contrast of what EBP is not to help determine the way forward as this represents a known point from which we can run clearly in the other direction. The below example is the epitome of times gone by in PT and hopefully a place we will never return.

Richard and others are certainly free to disagree (and I can count on an email from him shortly I suspect as to why I am wrong), but trying to convince someone that the SI joint moves in a clinically meaningful way is not a defensible position.

John

Email from Richard Don Tigny

HI John,
I just ran across you 2007 comments regarding my research.
Just thought I would bring you up to date on my more recent observations.
Pelvic dynamics have been essentially ignored for many years because it has been assumed that they were far too complex for anyone to analyze and because an early researcher reported essentially no movement in the sacroiliac joint. In 1965, I saw a patient who had recovered immediately from common low back pain through a fortuitous accident and I realized her pain was caused by a reversible, biomechanical lesion. Through the succeeding 45 years I have been able to successfully analyze these pelvic dynamics. Others probably could have done this in much less time, but none have chosen to do so.

Among some of the various items that I have uncovered are:
1. A bony transverse loading axis of the sacrum posterior to the S3 SIJ segment, verified by Gracovetsky.
2. Form and force closure ( Vleeming) only occur in the unloaded pelvis or in the cadaver pelvis. After the sacrum is loaded and the pelvis is symmetrical, a system of balanced ligaments causes a net 0 closing force at the sacroiliac joint.
3. The sacrum hangs from the posterior interosseous ligaments and the sacroiliac joint (SIJ) is essentially a non-weight bearing joint.
4. When the pelvis moves into asymmetry during normal gait, the innominate on the side of loading rotates caudad on an axis through the pubic symphysis and moves the sacrum caudad, but does not move caudad on the sacrum.
5. When the pelvis is asymmetrical the sacrum flexes laterally in the long straddle position to create an oblique sacral axis.
6. The sacrum moves on that oblique axis to drive counter rotation of the trunk in order to decrease loading on that side. This has a major effect on normal gait.
7. There are two prime movers of the sacroiliac joint, the piriformis and the sacral origin of the gluteus maximus, which function to restore pelvic symmetry at mid-step.
8. A biomechanical vulnerability of the pelvis to injury through minor trauma occurs with anterior rotation of the innominates on the sacrum and a loosening of the sacrotuberous ligament.
9. A shift in the line of gravity anterior to the acetabula disturbs the ligamentous balance and allows the innominates to move cephalad and laterally on the sacrum at S3 to subluxate and fixate. This is the cause of acute idiopathic low back pain with or without a non-disc sciatica.
10. The ilial tuberosities function to prevent any posterior functional or dysfunctional movement of the innominate on the sacrum.
11. Posterior rotation of the innominates on the sacrum and upslips are clinically insignificant, occurring at the S1 SIJ segment.
12. The dysfunction in anterior rotation causes a vertical shear on the conjoint origins of the gluteus maximus and the piriformis at the S3 SIJ segment, which is the cause of the piriformis syndrome.
13. The dysfunction in anterior rotation increases the lumbosacral angle and loosens the iliolumbar ligaments and increases shear on the lower lumbar discs. This may initiate a spondylolisthesis and is probably the cause of disc disease.
14. The dysfunction in anterior rotation may cause a reversible, biomechanical asymmetry of the pelvis with a reversible change in leg length.
15. Pain in the abdomen at Baer’s sacroiliac point is not uncommon with SIJD and is commonly the cause of unnecessary surgery. This point is on a line from the umbilicus to the anterior superior iliac spine, two inches from the umbilicus and pain there is relieved with corrections or injections to the SIJ.
16. It is possible to make a diagnosis of the dysfunction of the SIJ in anterior rotation merely by identifying a painful point at the posterior inferior iliac spine.
17. The conventional side-lying treatment of this dysfunction by chiropractors and physical therapists will eventually cause the long posterior ligaments to become unstable and is probably now the chief cause of chronic low back pain.
18. Increased loading of the femoral head from a non-functioning SIJ may cause microfractures in the subchondral bone with roughening of the joint surface and eventual arthritic changes.
19. Dysfunction of the SIJ in anterior rotation loosens the muscles and ligaments of the pelvic floor and correction to the balanced position tightens the pelvic floor.
20. Sturesson made a procedural error in his measurements of the SIJ and wound up measuring a symmetrical pelvis in the long straddle position. Smidt was correct. See x-rays at www.thelowback.com .
Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints. A roentgen stereophoto-grametric analysis. Spine 14:162-165, 1989
. Smidt GS, McQuade K, Wei SH, Barakatt E: Sacroiliac kinematics for reciprocal stride positions. Spine 20(9):1047-1054, 1995
DonTigny RL: Sacroiliac 101: Form and Function - A Biomechanical Study. J of Prolotherapy, 3(1): 561-567, 2011
21. With full correction of the dysfunction of the SIJ in anterior rotation, at least 85-90% of all patients will be essentially free of pain within about ten minutes.
X-ray evidence of SIJ movement is on my website as well as many illustrations of pelvic dynamics.
I invite you and your colleagues to visit at www.thelowback.com, How it works, why it hurts and how to fix it. My bibliography is also on that website. I also have a CD for professionals with over 650 slides and 150 illustrations.

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

"Trial of #physicaltherapy" Pet Peeve #2

We started a series entitled Physical Therapist Pet Peeves a few weeks ago with #1 being the term “skilled physical therapy”.

Pet Peeve #2 is the the referral for a “trial of physical therapy”.  The scenario usually unfolds like this.  A patient with low back pain who has been seen by their primary care doctor is now referred to a spine doc.  The first level of treatment was a “trial of anti-inflammatories” and in all likelihood pain medication.  Since the patient didn’t respond entirely to the meds and complaints include some radiation to the leg, the patient was referred to a “specialist” who ordered an MRI (and if the doc owned the MRI, evidence shows it was self-referred).  There was undoubtedly seen some “bulging disk(s)”.  The specialist believes that surgery would relieve the symptoms. However, the patients insurance will not approve the surgery unless a “trial of physical therapy” did not result in improvement.  The conversation:  “Mrs. Jones, you need surgery. Unfortunately, your $%X@^ insurance company won’t let me help you and they say you have to have a “trial physical therapy” which of course can’t possibly help a surgical condition.  Perhaps it was a little softer conversation, “Mrs. Jones, you need surgery but let’s do a “trial of physical therapy””.    In all likelihood, this “trial” was done in the physician’s own PT clinic.  Regardless of where treatment was sought, there is no basis or assurance that the physical therapist upholds the best current evidence in the treatment of LBP (another post for another time).  I refer to this scenario which occurs every day (and several times a day if you live in Greeley, CO), as being “set up by the knife”.   

Today, the so called “Iowa study” was published which shows not surprisingly that directly accessing a PT results in lower overall cost associated with the initiating complaint and less visits then when referred by a physician to a physical therapist.  Imagine if patient consumers really weren’t brainwashed by language such as “trial of physical therapy”. Just imagine the savings in unnecessary tests and medications (or just read this post about a recent published paper of the impact of direct access for LBP).  With 2 legs of the stool now in the public domain (direct access and savings in downstream costs for LBP done by a PT), we now only need a referral for profit study published to propel independent PT’s to the upper echelon of the food chain.

We don’t tell patients, “you appear to have an ear infection, let’s do a “trial of primary care””.  We don’t tell patients, “you have torn ACL, let’s do a “trial of orthopedic surgery””.  So, it is time to represent physical therapists as what we are, a solution and the preferred specialist referral option based on evidence, not a modality with the same poor odds of success as an anti-inflammatory medication.

Thoughts?

@physicaltherapy 

This patient really does exist. He’s a rancher down here in South Texas. 5am he’s already out digging fence posts, pulling wire, pitching hay, or rebuilding cattle guards…and he stays at it until dusk, occasionally stopping for a glass of ice tea or a taco.

 

We’ve all seen this type of referral at one point or another. The question is how to handle it when it comes. Do we take responsibility for this patient’s outcome and simply ignore the referral requests? Do we follow the requests and then blame the shoddy outcomes on the referring provider? Or maybe we allow that gnawing feeling in our viscera loose to argue the valor of current EBP or just the sheer stupidity of the logic in “no active exercise” to the referring provider.

How do you coach your residents or fellows to handle these?

I think that a good approach with this type of encounter is to be very direct. Pick up the phone or get over there and visit the doc.

Seek to understand first.

  Why is he so specific in his requests? You'd like to understand... He may have had a bad experience with a PT or he may be looking simply for pain relief and not wanting to "stimulate" the irritated nerve region too much... etc. Get his perspective (don't start off trying to change it), and then gently and humbly answer his concerns and offer why the EBP approach can perhaps better reach his aim/intent which is hopefully yours as well.

 

Bottom line: Look to build a relationship and collaborate with this referring provider vs. compete for "best knowledge" on managing these patients. His student loans are larger than yours. His perspective is that he's got the edge on "best knowledge".

ab

@bennettab

andrew@texpts.com