Physical Therapy's Unholy Alliance

This post well-summarizes the recent House and Senate vote on the Medicare Physician's Fee Schedule.

My response to the post recommends ending or reducing not only the bi-annual Medicare lobbying bonanza and PAC funding spree but also the "unholy alliance between providers, payers and patients" (I'm quoting myself).

Here is the response from the American Medical Association to Friday's Senate vote:

***

Statement Attributable to:
Nancy H. Nielsen, M.D.
President, American Medical Association

"The physicians of America are outraged that a group of Republican senators followed the direction of the Bush Administration and voted to protect health insurance companies at the expense of America’s seniors, disabled and military families.

"These senators leave for their 4th of July picnics knowing that the most vulnerable Americans are at risk ...

"...Today, thanks to some senators, we stand at the brink of a Medicare meltdown. On July 1 – just four days from now – the government will slash Medicare physician payments by 10.6 percent, forcing many physicians to make the difficult choice to limit the number of Medicare patients in their practices.

"The Senate must return from their recess and make seniors’ health care their top priority. For doctors, this is not a partisan issue - it's a patient access issue."

***

(here I respond to her original post)

While I agree with the facts of your post I wonder if the rhetoric of the AMA well serves the American public (especially the 46 million uninsured, mainly women and kids).

Instead of bi-annual(we went through this in December 2007 - remember?) 10% Medicare cuts why not a 2% annual reduction in the Medicare Physician's Fee Schedule?

Everyone knows the direction federally funded healthcare reimbursement has to go.

Large cuts inevitably trigger PAC funding and large-scale lobbying to reduce or reverse the cuts.

More money is not the answer.

One solution to the healthcare "crisis" is to dissolve the unholy alliance of providers, payers and patients.

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Can patients afford healthcare without heavy regulation and government intervention?

That is, would there be a healthcare system without insurance companies and Medicare?

Many economists don't think so.

Nevertheless, physical therapy is well-suited to provide services to patients in gyms, schools, industry workplaces and to private-pay, 'cash practices' that would avoid the need for the third party arrangement that dominates healthcare today.

Physical therapists provide value with every intervention.

See how to provide valuable, audit-proof physical therapy for Medicare patients in outpatient physical therapy clinics.

Medicare recovery audit contractors

Physical therapists are another healthcare provider that will get caught in Medicare RAC audits, as I posted on June 20th.

Medicare recovery audit contractors (RAC) draws criticism from stakeholders - 06/25/08.

The article states the following...

"The RAC, which, according to Smith, acted in an aggressive manner, also cited a lack of documentation regarding documents that the practice had provided in electronic format."

Once again, the problem stems from a lack of documentation.

Physical therapists need a simple way to document the services they provide.

Physical therapists need to quickly and accurately show the following:

1) Medical Necessity for Physical Therapy

2) Skilled Physical Therapy Services

3) Expected Improvement in a Reasonable Time Frame

How can a Physical Therapy manager do this consistently?

Get Bulletproof Physical Therapy Charts and Notes

Go to Bulletproof-PT-Charts.com

Sleep Well.

Medical Fraud a Growing Problem - washingtonpost.com

To anyone who follow physical therapy compliance and Medicare anti-fraud activity the case of Rita Campos Ramirez is nothing new.

The media sound bites indicate that Ms. Ramirez was able to bill her charges with just a laptop computer and that she had no more than a high school education.

The Washington Post article emphasizes the simplicity and the size of the problem.

Ms. Ramirez charged 140,000 Medicare claims for HIV drug therapy.

The article states that most of the south Florida Medicare fraud focuses on the following:

"...schemes center on expensive, infusion-based HIV medications and on equipment such as wheelchairs, walkers, canes and hospital beds."

The problem is that honest, hard-working physical therapists get lumped in with the evil-doers.

"Officials from the Centers for Medicare and Medicaid Services (CMS), which oversees federally funded health programs, say they have stepped up their efforts to combat fraud over the past year by working closely with investigators, removing the requisite billing numbers of nearly 900 companies and imposing new standards in high-fraud areas..."

What physical therapists really need is a simple way to comply with current regulations, not more regulations.

Physical Therapy's Economic Moat

Athletic trainers would like to learn techniques from physical therapists and to bill physical therapy (97000 series) codes to Medicare.

The American Physical Therapy Association (APTA) would like to prevent athletic trainers from learning these skills and from billing Medicare.

The National Athletic Trainers Association (NATA) has launched legal action for what it calls 'anti-competitive' behavior on the part of the APTA.

The APTA has responded in kind. Read this post from APTA President R. Scott Ward.

The APTA maintains a page on its website with supporting information on athletic trainers and Medicare.

When the weapons in the competitive landscape are legalistic volleys rather than genuine consumer value I question if physical therapy truly has a sustainable competitive advantage over athletic trainers (or any other competing profession).

Before well-meaning physical therapists respond to that last statement let me show you a quick example of how an economist might 'value' the physical therapy profession.

Morningstar is an investor's information source (website, newsletters, consulting, etc.) that has created several proprietary systems for understanding the social and financial value created by companies and industries.

Morningstar (and Warren Buffet) have created a concept for defining company value called the 'sustainable competitive advantage'.

"The competitive advantage ... is important because it's one of the primary considerations when determining the value of a company."

Mornigstar's model of company valuation can be helpful in understanding the economic future of the physical therapy industry.

Morningstar lists the following four criteria in determining if a business has a sustainable competitive advantage (Morningstar calls this the 'economic moat') :

"First, has the company made it tough for customers to switch from its products to those of the competition?"

Medicare regulation makes it difficult for consumers (patients) to switch from physical therapists to athletic trainers because Medicare will not pay athletic trainers to provide physical therapy services.

"Second, does the firm have lower costs than competitors?"

Athletic trainers median salary, from the US Department of Labor, Bureau of Labor Statistics is as follows:

Percentile wage estimates for... (Athletic Trainers):

Percentile	10%	25%	50% (Median)	75%	90%
Annual Wage	$23,430	$31,060	$38,360	$47,820	$60,180

Percentile wage estimates for... (Physical Therapists):

Percentile	10%	25%	50% (Median)	75%	90%
Hourly Wage	$23.33	$27.83	$33.54	$39.49	$48.12
Annual Wage	$48,530	$57,880	$69,760	$82,140	$100,080

The NATA maintains that athletic trainers can provide physical therapy services at lower cost than physical therapists.

"Third, does the company have an intangible asset that makes it tough for competitors to take its business? Patents, trademarks, and regulatory approvals are the most obvious examples here, but brand names or a tough-to-replicate geographical advantage would also fall in this category."

It is hard to argue that physical therapy has intangible 'assets' that qualify physical therapy over athletic trainers - in the eyes of the patient.

I know some physical therapists might argue that point.

The APTA would argue that patient safety is compromised under the care of an athletic trainer.

I'll leave that discussion for another post (or another blogger).

"Finally, does the company benefit from network economics, in which its service or product becomes more valuable the more users it has?"

The short answer to the forth criteria is no.

In summary, the only sustainable competitive advantage that physical therapy has (from an investors standpoint) over athletic trainers is that Medicare regulations impose high 'switching costs' on patients, thereby preserving the physical therapists' 'economic moat' .

So, physical therapists' appreciation, PAC dollars and volunteer support should go to R. Scott Ward and all the folks at the APTA for helping to preserve for physical therapists the single, solitary advantage (from an economist's perspective) that physical therapists have over athletic trainers.

Or, are there others?

What else can physical therapists provide that athletic trainers can't provide?

What about Physical Therapy Diagnosis?

Physical Therapy Decisions

Are physical therapists drowning in an ocean of medical information?

Journals, articles, continuing educations courses, new textbooks, government regulations and professional position statements are just a few of the complex reading requirements that physical therapists must digest.

Selena Horner posts at www.MyPhysicalTherapySpace.com in a post titled Overwhelmingly Complex
.

She asks the following...

"Is there a way to move from overwhelmingly complex to simple?"

Selena Horner

Joel Bialosky, Stephen George and Mark Bishop ask How Spinal Manipulative Therapy Works: Why ask Why? in the guest editorial of the June Journal of Orthopedic and Sports Physical Therapy.

Somewhat paradoxically, Bialosky et al state the following:

"More information on how and why spinal manipulative therapy
works may lead to higher utilization rates because there would be less skepticism
about rationale for its effectiveness and less mysticism surrounding its use."

Finally, in 2006 the Orthopedic Section of the APTA began a project called...

Use of the International Classification of Functioning and Disability to Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions

.

The authors, Joseph Godges, DPT, MA, OCS Coordinator, ICF-Based Clinical Practice Guidelines and James J. Irrgang, PT, PhD, ATC Orthopaedic Section President state the following:

"It is believed that these guidelines will advance orthopaedic physical therapist practice and could be used to guide professional and postprofessional education and to establish an agenda for future clinical research."

Ultimately, the goal of academic research should be to improve clinical physical therapy.

Ms. Horner's original question asked how to make the complex into the simple.

I think each of these examples, in its own way, seeks to do one thing - improve physical therapist clinical decision making.

For the practicing physical therapist clinician (and the lab researcher) better physical therapy decisions come down to one thing:

Measurements.

Take better measurements of your patients to make better treatment decisions.

I recommend a simple system for management of lower quarter and lumbar dysfunction, interestingly called SIMPLE for Summary of Impairments of the Lumbar Spine and the Lower Extremity.

Take a look at it at the SIMPLE website.

I also recommend an excellent textbook on Physical Therapy Diagnosis which you can get here...

Physical Therapy and the International Classification of Functioning and Disability

The Orthopedic Section of the APTA (and others, I assume) is attempting to link 'academic physical therapy' - typically viewed as too esoteric - with clinical physical therapy with a new model of describing common conditions seen in physical therapy patients.

The Orthopedic Section has a position statement on the following topic...

Use of the International Classification of Functioning and Disability (ICF) to Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions

Joseph Godges, DPT, MA, OCS
Coordinator, ICF-Based Clinical Practice Guidelines

James J. Irrgang, PT, PhD, ATC
Orthopaedic Section President

The details are preliminary but the final goal is to guide physical therapy decision-making.

For example, how should a student physical therapist classify a patient with a physician's diagnosis of 'frozen shoulder? The ICF Shoulder Guidelines can instruct the new graduate how to perform the evaluation and diagnosis.

The ICF Lower Back Pain Guidelines are complicated and focus heavily on classification.

Physical Therapy Diagnosis can do much the same for lower back and lower quarter dysfunction using the SIMPLE system (details at www.SimpleScore.com).

If classification can guide daily treatment decisions then I encourage the new graduate and the 'old school' physical therapist to learn the ICF model.

The SIMPLE (Summary of Impairments of the Lumbar Spine and Extremities) system provides much the same in a more intuitive manner.

Link your measured impairments with the patients' self-reported functional limitations in order to improve your decision making.

More people will get 'more better' if you make it easy for them.

Physical therapy should be simple.