The Physical Therapy Acid Test

Physical therapy is a commodity.

That's the conclusion I reach when I ask my peers at work, writers on blogs and members of e-mail list-serves the following question...

"What is physical therapy?"

I usually get a strange look followed by a textbook answer along the lines of 'Physical therapy is the assessment and treatment of movement dysfunction...'

This answer strikes me as too wordy and rehearsed.

Physical therapy needs a better answer to that question.

I recently ran across this 'acid test' in the print version of BtoB: The Magazine for Marketing Strategists. The article was on the declining 'brand equity' of major United States airlines.

"The acid test, he said, is simply to ask what an airline stands for. “What does United Airlines stand for?” he asked. “If you have to stop and think for more than three seconds to find a single word to describe them, then they're a commodity.”

Physical therapy needs a single unifying theme that creates a wide economic moat that other professions cannot infringe.

That theme should be measurement.

Measurement leads to physical therapy diagnosis.

Physical therapy diagnosis is a prerequisite for the 'holy grail' of health care ...

prognosis

"How much will it cost?"

"How long will it take?"

What is physical therapy?

Physical therapy is measurement.

There! Passed the acid test.

The New Physical Therapy

"All models are wrong, but some are useful" begins the Wired Magazine article The End of Theory.

The article, by Chris Anderson (of The Long Tail fame), goes on to explain that in this current 'era of massively abundant data' scientists have become less reliant on the age old tradition of creating plausible models and testing hypotheses to refute or deny the model.

Instead, scientists can merely find correlations is massive data sets that have been, heretofore, unavailable for study and searching.

The power of sufficient data allows us to say "Correlation is enough" (Anderson).

Physical therapy has embraced this new thinking since 2002.

A manipulation decision rule was published in Spine magazine that laid out 5 predictor variables PT clinicians could test for: the presence of 3/5 variables implied that the patient was a good candidate for manipulation.

Anderson states that massively abundant data

"forces us to view data mathematically first and establish a context for it later."

The researchers first measured their physical therapy patients with dozens of 'traditional' physical therapy test and measures.

They then dumped the results of these measurements (some good, some bad) into a statistical 'hopper' and compared the results with the patients that got better.

Those tests that best predicted the patients that got better were the final predictor variables.

To paraphrase Anderson...

Who knows why patients get better? The point is that patients do get better and we can track and measure those patients with increasing accuracy.

"With enough data, the numbers speak for themselves"

Measurements are the key, however. Without measurements we cannot draw correlations.

Even Google could not search web pages if no one bothered to post their data.

The Physical Therapy Value Proposition

I've received notice that my value proposition is not as clear and logical as I thought it was.

My thanks to Larry Benz, PT Selena Horner, PT and Mark Schwall, PT for commenting on several of my last posts.

I'll try again.

Physical therapists measure patients:

• ROM
• strength
• extremity girth
• difficulty with activities (OPTIMAL)
• Fear-Avoidance Beliefs
• isometric lumbar extension strength
• the list goes on...

The measurements and the interpretation of these measurements is all that separates physical therapists from other professions that do many of the same interventions we do:

• specialized exercise by personal trainers
• massage by massage therapists
• spinal manipulation by chiropractors and osteopaths
• ultrasound and electric stimulation by athletic trainers
• splint and orthotic fabrication by orthotists and occupational therapists

Going forward, my recommendation is that physical therapists hang their hats on simple physical therapy measurements as the value proposition to the consumer.

Consumers like value.

Consumers include the following:

• Patients
• Insurance companies
• Medicare
• Industrial work places
• Schools
• Military

The value created in the exchange between the patient and the physical therapist is information.

Simple measurements create information which is valuable.

I'll give one example...

You measure a weak external rotator muscle and advise the patient that overhead lifting or throwing sports are risky because the likelihood of impingement and eventual tear is increased.

You have created new information that did not exist prior to your exchange with the patient.

You have demonstrated the medical necessity for physical therapy.

You have demonstrated skilled physical therapy.

Physical therapists need to take more measurements of their patients in order to create additional value during the exchange.

Outcomes are one type of measurement. The OPTIMAL is an outcome measure.

But measurements are also predictive. Measurements taken during the evaluation help the physical therapist select interventions and set long term goals.

Measurements allow physical therapists to classify patients.

Measurements allow the physical therapist to make a physical therapy diagnosis and, ultimately, a prognosis.

Without measurement there is no value in physical therapy.

'Educated' Physical Therapist Sells Out Profession

I'm posting the most interesting parts of a conversation between Larry Benz, PT at MyPhysicalTherapySpace.com and Tim Richardson, PT of PhysicalTherapyDiagnosis.com about so-called 'below cost' reimbursement rates.

The first installment is Larry's link (above), to which I have responded on his blog.

His reply is next...

From the original post on MyPhysicalTherapySpace.com Larry writes the following...

"Tim:

Just trying to understand your perspective on the economics of this (physical therapy clinics accepting low reimbursement rates).

Agree with you on value.

It is impossible to do any delivery irrespective of financial viability.

Cannot understand how taking contracts below Medicare rates is fiscally responsible.

It is that type of financial naiveté that has led PT's to take rates at $40 per visit enacting the never ending limbo negotiations that occur ("how low can you go")."

To which I responded:

Larry,

I guess it depends on your size.

A small practice PT has better things to do with his time than treat patients for $40/visit (play with kids, fish, sleep).

A large PT practice with large fixed costs has to keep the dollars rolling in.

Any amount over your variable cost per visit is profit.

It's the same model the airlines use.

Ask you seat partner next time you fly...

"How much did you pay for your seat?"

If his is less than yours - why?

If yours is less than his - why?

The variable cost to transport one additional passenger is the cost of a bag of peanuts.

The rest is profit.

Same with PT.

Read this article. I use PT specific examples with graphs and charts.

'Stay Small and Make Big Profits' (August 2007 PT Products Online)

Tim

Physical Therapy is not a 'Loss Leader'!

Some physical therapists think that refusing to accept 'loss leader' patients from Medicare Advantage plans will preserve physical therapists' pricing power.

A loss leader (in retail) is a product that is priced less than it's cost to produce. For example, Office Depot might advertise reams of copy paper at $30.99 for a case for a catalog order but the Office Depot web site has that same case for $44.99.

Office Depot will take an up-front loss in order to get you to use their catalog. They are counting on higher order volume (more items) with each catalog order.

The catalog represents a fixed-cost investment that Office Depot must amortize through higher order volume. The Office Depot web site is a relatively low-cost distribution channel that can be profitable on lower sales volumes.

What has this example got to do with physical therapy private practices?

Physical therapy private practices are fixed-cost investments for their owners. The owners only get paid back on these investments when revenues exceed costs.

Once your fixed costs (such as rent, salaries and utilities) are met you must still pay variable costs.

The variable cost to treat the Medicare Advantage patient is the cost of the ultrasound jelly you smoosh on her neck.

That's not very much.

Medicare Advantage rates are (still) higher than the one smoosh of ultrasound jelly.

You make more money than you lose when your reimbursement rates exceed your variable costs of keeping your doors open.

Cash is King

Physical therapy practice owners with full-time employees realize that pay day comes every two weeks whether or not cash is in the bank or not.

High-volume Medicare Advantage patients on your caseload prevents your employee physical therapists from sitting idle.

Yes, Medicare Advantage pays less than Medicare.

Yes, you will lower your profit margin (but you will survive).

Yes, you may ask your physical therapist employees to see more than one patient per hour.

No, you may not use aides to treat your patients (any patients - not just Medicare patients).

How, you may ask, should a struggling PT private practice owner survive?

My recommendation...?

Find out why your patient hurts.

Make the physical therapy diagnosis.

Treat the cause of their pain.

Treat the actual change in 'body structure and function' that has lead to their painful, dysfunctional state.

Tell them why they hurt and why they can't lift things up and why they can't walk more than a city block.

You must have the skills and the ability to measure deviations from normal that qualify your patient for physical therapy.

The growth in physical therapy over the last 30 years is a real trend that reflects real demand.

The value of physical therapy is undeniable.

The cost of physical therapy, however, is climbing and is subject to policy and political whims.

Physical therapy will not go away with changes in Medicare reimbursement rates.

Your physical therapy practice may go away, though.

Change is inevitable.

What will you do to create the future for you, your patients and your country?

To learn how to measure, diagnose and treat your patients better get this free tutorial.

Measurements Equals Value for Medicare

Medicare wants measurable data for a compliant physical therapy chart?

Fine.

Here's a new way to measure the strength of the external rotator of the shoulder using the common goniometer.

This measure is easy, quick and reliable (reliability data not published).

It works better than Manual Muscle Testing.

I use this measurement every day in my clinic to document the treat ment of Medicare shoulder impingement patients.

The measurements lend themselves to long term goal setting for the physical therapy chart.

I measure shoulder dysfunction in patients that some physicians don't recognize.

The measurements are accurate enough to gauge the progress of the patient.

This technique will segue to a home exercise program in a heartbeat.

I can diagnose shoulder joint stiffness.

I can diagnose shoulder muscle (ER) weakness.

You can, too.

See more simple measurement techniques at www.simplescore.com

Sign up for the free course - 'Bulletproof Physical Therapy Charts and Notes'.

Physical therapists take note of Medicare audit process

The MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) Program: An Evaluation of the 3-Year Demonstration June 2008
report is available here (downloadable PDF).

Interpretations differ but most call the program a success citing the high amount recovered and the low amount recovered on appeal.

The Recovery Audit Contractors have recovered more than one billion dollars.

Amounts overturned on appeal were low...

"As of March 27, 2008, providers had chosen to
appeal 14.0 percent of the RAC determinations.
Of all the RAC overpayment determinations, only
4.6 percent were overturned on appeal."

Overpayments by provider type showed that physicians (which include outpatient physical therapists) accounted for only 2.5% of the total overpayments collected.

While some feel that the RAC program is on a 'bounty hunt' the results of this report that, not only are RACs here to stay but that soon they will be in all 50 states.

George Bush supports Physical Therapy payments

President George Bush vetoed H.R. 6331, which maintains Medicare payments to medical providers yesterday, including physical therapists, on fiscal and ideological grounds.

In his message to the House of Representatives, Mr. Bush states the following:

"This bill is objectionable, and I am vetoing it because:

It would harm beneficiaries by taking private health plan options away from them; already more than 9.6 million beneficiaries, many of whom are considered lower-income, have chosen to join a Medicare Advantage (MA) plan, and it is estimated that this bill would decrease MA enrollment by about 2.3 million individuals in 2013 relative to the program's current baseline.

It would undermine the Medicare prescription drug program, which today is effectively providing coverage to 32 million beneficiaries directly through competitive private plans or through Medicare-subsidized retirement plans.

It is fiscally irresponsible, and it would imperil the long-term fiscal soundness of Medicare by using short-term budget gimmicks that do not solve the problem; the result would be a steep and unrealistic payment cut for physicians -- roughly 20 percent in 2010 -- likely leading to yet another expensive temporary fix; and the bill would also perpetuate wasteful overpayments to medical equipment suppliers."

After the veto H.R. 6331 was sent back to Congress...

"The House passed this legislation by a 383-41 vote and by a 70-26 Senate vote. A two-thirds vote was needed by the House and the Senate to override the Presidential veto. Once the Senate voted to approve HR 6331, it now becomes law immediately. (LA Times)"

Private practice physical therapists are obviously happy.

My practice would have seen a dramatic decline in cash flow from Medicare.

We staff our office with physical therapists and physical therapist assistants specifically because Medicare patients need that level of expertise (most Medicare patients are elderly).

I might have had to lay off staff.

Nevertheless, the president is right when he says the following:

"...it would imperil the long-term fiscal soundness of Medicare by using short-term budget gimmicks that do not solve the problem; the result would be a steep and unrealistic payment cut for physicians -- roughly 20 percent in 2010 -- likely leading to yet another expensive temporary fix..."

I posted my solution on July 1.

Let's hear from you.

Can we help fix (at least) physical therapy in the health care system?

Post your comments.

New Physical Therapy Paradigm

There is a new game in town.

Physical therapists may have to hit the hit the books again to learn the new disability paradigm...

APTA Endorses World Health Organization International Classification of Function Model

In school (I graduated in 1992 from the University of Florida), we learned about impairments in range-of-motion and strength.

We learned about disability and how physical therapists can help people.

We learned that physical therapists link impairments to disability via the physical therapy diagnosis.

Now, the link is the same.

Physical therapists still do the same thing.

The names have changed.

The new ICF model uses new terms.

The terms are important because words direct thinking.

Words are powerful. Words are labels.

Words like Disablement = Participation.

Words like Functional Limitation = Activities.

Words like Impairment = Body Structure and Function.

The American Physical Therapy Association has gotten behind the new paradigm.

Soon, educational programs will get on board.

Then, your students and new graduate physical therapists will arrive...

...talking the new language of Participation, Activities, Body Structure and Function.

Then Medicare will get on board.

Then, you will have to get the new paradigm.

Get it now. Get the new paradigm. Because it's good for your patients.

Because it can help your clinical decision-making.

Learn how you can work this new paradigm into your clinical practice.

Get Bulletproof Physical Therapy Charts and Notes.

Get it.

APTA Endorses World Health Organization ICF Model

The American Physical Therapy Association (APTA) recently endorsed the new World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Model.

I doubt most physicians consider disability when making a physical therapy referral.

Most medical doctors consider pathology first.

The first line intervention for pathology is usually pharmaceuticals.

Disability , and the physical impairments that lead to disability, is better addressed through physical therapy interventions such as Therapeutic Exercise (CPT 97110), Manual Therapy (CPT 97140) and other active interventions.

In the new model Impairments are replaced with 'Body Function & Structure'.

Functional Limitations are replaced with 'Activities'.

Disabilties are replaced with Participation.

Physical therapists are usually pretty familiar with the concept of disablement.

Medicare, in the United States, specifically pays physical therapists to treat disability, not pain.

The Orthopedic Section of the APTA is using the new ICF model to "Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions".

The 'potential benefits of the project are to identify appropriate outcome measures'.

Currently, Medicare recommends the OPTIMAL scale for outcomes in outpatient physical therapy.

Watch OPTIMAL videos to use it for Medicare long term goal setting.

Medicare Saves 700 Million in Overpayments to Providers

I question whether all of these dollars are recovered from 'fraudulent activity'.

Medicare Overpayments - Wall Street journal headline

This press release from the Recovery Audit Contractors declares their high standards.

Does any reader of this blog have any experience with a Medicare audit?

Does any reader of this blog have any tips to prevent or survive a Medicare audit?

20% Medicare Physical Therapy cuts in 2009

The US Senate, on July 9, 2008, overwhelmingly passed their version of HR 6331, designed to prevent the 10.6% cut in the Physicans' Fee Schedule and reinstate the Automatic Exceptions Process to the Physical Therapy $1,810 benefits cap.

The physical therapy benefits caps arbitrarily imposes the cap once outpatient physical therapy charges reach $1,810. Thus, those patients who need physical therapy care the most are harmed the most.

One of my patients, an elderly grandmother had her left knee replaced on June 1. For four weeks she had to use a walker to get from her bed to her bathroom and caused her right elbow to hurt.

June 20th she saw her orthopedic surgeon who said she now has developed osteoarthritis in her left shoulder and needs the shoulder replaced.

On June 29th the "regularly-scheduled hostage crisis" in the US Senate had Americans and their health care providers anxiously waiting to see which way the budget ax would fall.

So far the ax hasn't fallen on my elderly grandmother - she has been able to get her physical therapy at the hospital. Hospital outpatient physical therapy departments are exempt from the cap.

Ironically, the passage of HR 6331 sets the stage for a 20% Medicare cut in December 2009.

Pete Sepp of the Shreveport Times says the following:

"The outcome of this drama depends on whether politicians enact modest reforms sooner to avoid catastrophe later."

As I posted before the Senate vote I recommended an annual 2% cut to the Physicians' (and physical therapists') Fee Schedule.

The American Medical Association (and the APTA)would be unable to register sufficient voter and constituent indignation to counter the cut.

I don't want a 2% to my practice revenues but I, just like all Americans, can see the writing on the wall.

We've made the diagnosis.

Diagnosis is necessary for prognosis.

Now is time for some bitter medicine, before it' too late.

Senate Overwhelmingly Passes Medicare Bill

Physical Therapy Valuable to the United States Senate

An overdue victory for health care providers delayed for now the eventual showdown over Medicare payments to physicians and physical therapists treating almost 50 million senior Americans.

Democrat Senator Ted Kennedy returned today to cast his vote in the Senate which overwhelmingly passed the Medicare bill (H.R. 6331)

"The legislation--which fell just one vote shy of passage less than two weeks ago ...was approved 69 to 30, a veto-proof margin. (Washington Post, 7/9/08)"

H.R. 6331 will now be sent to President George Bush for a signature.

Of particular interest to physical therapists is the fact that H.R. 6331 restores the Automatic Exceptions Process that allows Medicare patients to obtain needed physical therapy services in excess of the $1810 per beneficiary cap.

The recommendations of the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Cap Report (Mar. 21, 2008) indicates that the Exceptions Process allows patient access to Physical Therapy while saving the government money.

"The cap-specific analysis findings in this report suggest that the elimination of the cap exceptions process on July 1, 2008 would have dramatic and significant impact on beneficiaries with clearly identified demographic and diagnosis characteristics, and would also disproportionately impact those provider settings where such beneficiaries receive services, similar to that observed in CY 1999."

So, Medicare (and the U.S. Senate) recognizes that physical therapy is valuable.

Value, to Medicare, is calculated by this simple equation Value = Quality / Cost.

Cost is simple to calculate - I discussed cost in my last blog post.

So, what is Quality?

How can you determine the Quality of physical therapy?

Your patient can tell you.

Maybe the doctor can tell you.

Maybe your peers can tell you.

But, how do physical therapists tell Medicare (and the U.S. Senate) the Quality of physical therapy?

Outcomes.

Get used to outcomes.

Get comfortable with outcomes.

Just get them.

Some outcomes systems I recommend include the following:

The OPTIMAL scale (recommended by Medicare)

Focus on Therapeutic Outcomes (FOTO)


The Oswestry Disability Questionnaire

The Neck Disability Index

The Patient Specific Functional Scale

Also, if you are a physical therapist in the United States, I recommend a program called Bulletproof Physical Therapy Charts and Notes.

I wrote it.

It's free.

And it may help you avoid a Medicare audit.

Medicare Audits to Educate Doctors

A step in the right direction?

The new, nationwide Medicare Recovery Audit Contractor program will attempt to educate physicians on proper billing and documentation procedures.

The American Medical Association still complains and who can blame them?

Medicare audit overreach? Doctors think so, but audits aren't going away (July 7, 2008) American Medical News

"The program has been extremely burdensome on affected physicians and does nothing to educate them about common billing mistakes,' said AMA Board of Trustees member William A. Dolan, MD.

The permanent program will focus more on schooling physicians about errors than on punishing them for it, said Timothy B. Hill, the CMS office of financial management's director. The agency, however, has revealed few details about the extent of the education."

Physical therapists can get Bulletproof Physical Therapy Charts and Notes for free.

Don't wait for the government to do it for you.

Get yours now!

Cut Medicare to Increase Physical Therapy Value Proposition?

American Physical Therapy Association applauds Senator Max Baucus for standing up against efforts to abolish the Automatic Exceptions Process to the Medicare Physical Therapy Cap.

The Automatic Exceptions Process is an essential mechanism to assure that physical therapy services are accessible by the people who need it most.

A recent study ordered by the Centers for Medicare and Medicaid Services (CMS) found that, due to the cap, for the first time since 1999 the cost and the growth in physical therapy expenditures declined during 2006.

The... "study reveals that from CY 2004-2006, although the total number of therapy users continued to increase by 3.5% the overall expenditures actually decreased 4.7%.

This represents the first observed negative growth in payments per beneficiary since the implementation of the therapy caps during CY 1999."

Further, the intended effects of the Medicare cap appeared to be met since the number of beneficiaries accessing physical therapy services actually increased in 2006 by 3.5%.

The mean payment per physical therapy user declined 8% in 2006.

The Medicare cap, first implemented in 1999, is the attempt by Medicare to limit the growth in federal physical therapy expenditures.


The Value Proposition


Medicare would like to measure the value for its health care dollar.

In 2006, Medicare spent $3.05 billion dollars on physical therapy.

From 2002-2004, the growth rate in expenditures was 26%.

The Medicare value proposition is Value = Quality / Cost.

Cost is easy to measure (see above).

Quality, however, is not.

Current projects, like Pay for Performance (P4P), are Medicare's attempt to measure quality.

Too many physical therapists dismiss attempts to measure quality.

What are we afraid of?

Al Amato, PT, MBA replies to a statement by made on August 12, 2007 by Larry Benz, PT that "P4P ...is a fad":

"The momentum is moving toward P4P. I think it imprudent that this trend be ignored. At the least, consider collecting outcomes to be able to compare your care to a national average."

Congratulations to Senator Max Baucus. He is taking a tough stance in the short run - standing up for physical therapy.

In the long run, however, Senator Baucus understands that physical therapy provides value to Medicare.

And to Americans.

Find other ways to measure the value of physical therapy.

See How to make a Physical Therapy Diagnosis

***

Destroy Healthcare in order to save it

Medicare wants to save healthcare providers by changing the system.

Ironically, Medicare and Congress are trying to save Medicare by making adjustments that threaten to destroy the health care system.

In order to give congress more time to act to prevent the 10.6% cut in the Physicians' Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) will pinch the cash-flow pipeline until at least July 15th.

Cash flow is the lifeblood of any business and represents the majority of payments to medical practices in retirement areas, such as Florida.

Kevin Schweers, a spokesman for the Department of Health and Human Services, said Monday the Centers for Medicare and Medicaid Services will hold doctors' Medicare claims for services delivered on or after July 1. Claims for services received on before June 30 will be processed as usual, he said. By holding claims for health care services that are delivered on or after July 1, CMS will not be making any payments on the 10.6 percent reduction until July 15 at the earliest," Schweers said.

The CMS action seems reminiscent of a statement attributed to an American major during the Vietnam war...

"After the village of Ben Tre was virtually destroyed, an American Major said to journalist Peter Arnett (who would become famous for his work on CNN during the Gulf War),

"It became necessary to destroy the village in order to save it."

The CMS freeze is designed to prevent providers' accounting workload from going up since retroactive changes to the fee schedule necessitate billing small amounts that increase billing volume without increasing provider revenues proportionally.

Local groups across the nation, such as the Manatee Medical Society, are mobilizing support to encourage the Senate to get behind HR 6331 the Medicare Improvements for Patients and Providers Act of 2008.

When the Senate re-convenes on July 7th the Senators will have another chance to vote to prevent the 10.6% cut to the Physicans' Fee Schedule.

Everyone knows the direction Medicare and social security must go down in order to supply the Baby Boomers with pension and health care services and funds.

Why not a 2% cut every year, scheduled and anticipated, rather than a draconian 10% that prompts a PAC funding and lobbying bonanza every six months?

As a physical therapist, I make a physical therapy diagnosis on every patient I treat.

A healthcare policymaker would diagnose the financing of the Medicare system as broken.