Are 'home grown' outcomes measures better than OPTIMAL?

For now, over half the physical therapists in the US can take comfort in their 'informal collection of data' rather than their use of standardized outcome measures.

They are in the majority.

A new study by Dr. Diane Jette in the February Physical Therapy Journal titled Use of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and Applications reveals that only 48% of physical therapists in the United States used standardized outcome measures.

For now, they are in the minority.

Similarly, only 40% of the physical therapists in New Zealand appear to use outcome measures.

For the present, there is no mandate that physical therapists use standardized outcomes measures to assess patients at baseline.

Instead, physical therapists seem to act based on a professional consensus which indicates a lack of solidarity on outcomes measures.

Rather than a mandate, Medicare 'recommends' the use of one of three outcomes measure to assess need and clinical progress in patients.

"Home grown" measures instead

Dr. Jette's study found that 'home grown' outcome measures are used by a surprising 22% of physical therapists.

Why use 'home grown' measures?

Are they better than one of the 'recommended' tools?

Are 'home grown' outcomes measures better than the OPTIMAL?

Physical therapists can use baseline outcome measures to direct the plan of care and increase the thoroughness of their evaluation.

Dr. Jette's article illustrates the essential limitation of all outcome measures:

Most clinicians do not see the value in using standardized outcome measures.

The dilemma of the outcomes measure value proposition leads to this premise:

Outcome measures are a policy-makers' solution to a problem faced by clinical physical therapists, namely:

"How do I know what my patient needs?"

Bottom line, policy-makers need a way to measure value for the $3.06 billion (2006) annually spent on Medicare outpatient physical therapy.

The majority of physical therapists will need to quickly adapt when mandated outcomes measures arrive within five-years time.

Then, it will be time for 'home-grown' to go home.

Should we privatize the PQRI program?

Here's a business model you should try: Government!

They want to monopolize health care but they have trouble introducing new products that people want.

Example: PQRI.

I just sat in on the Physician Quality Reporting Initiative (PQRI) in 2009: 2.0% Bonus Payment for Physical Therapy audio conference from the American Physical therapy Association (APTA).

You can buy the DVD of the seminar here.

Some past history

For 2007 only 16% of eligible professionals participated in Medicare's voluntary program with only one-half of those participants earning a bonus payment (56,722 providers).

Wow, if my results were that bad I'd be out of business!

Anyone ready to privatize the PQRI program?

Some future predictions

Here are some possible future uses of the data from PQRI:

– Contracting

– Tiering of providers ("I'm good, you're bad")

– Payment differentials ("I make more, you make less)"

– Network participation ("More dough based on who you know")

Should you participate in PQRI?

Full disclosure: I have yet to make a dime from PQRI and I've been doing this since July 2007.

But, I'm going to keep on.

Why?

Because 'Quality Measure Reporting' will soon be mandatory and if you don't participate you may see a 2% discount on your reimbursements.

Certain aspects of Medicare claims administration are already privatized: Recovery Audit Contractors are one successful example that still gives me sleepless nights.

Should government privatize the PQRI program?

People use Health Information Technology

Some people are pessimistic about the benefits of health care information technology.

Some people say health care IT might be dangerous.

Don't bet against it.

Some people estimate a $90 billion return on investment (ROI) in 10 years.

Don't bet on it.

I think the return will be positive, maybe not in dollars - but maybe in lives.

I just started investing in health care IT: $4,800 for new software and $5,000 for a new server and installation.

We've been at it for one month now.

We're not quite there yet.

Reinventing the physical therapy chart electronically means I have to undo years of 'training'.

The hardest part is time - time spent re-creating clinical templates, work flows and data collection.

Time spent away from patients is lost revenue - that's another 'investment

I might be tempted to get depressed or pessimistic about the process.

I might not see a big, positive return on my dollars.

But, I'm going to keep trying.

Some people think computers will improve our future.

Spend Money on Health Care to Stimulate Demand

Physical therapists face a 15.1% pay cut in 2010.

Congress can prevent these cuts by voting to prevent an update to the much-hated Sustainable Growth Rate (SGR) portion of the physicians' fee schedule.

Why should Congress act on behalf of physical therapists?

Self-interest, to put it bluntly.

Congressional and American self-interest.

Physical therapy jobs are an important part of the United States economy.

Health care jobs are reponsible for half the job growth in the US economy since 2001.

"The good news is that if the housing market falls into a deep swoon,
health care could provide enough new jobs to prevent a wider recession."

But, the flip side of this upward trend is the larger trend of excessive US borrowing:

"...one explanation for the huge U.S. trade deficit is that the country is borrowing from overseas to fund creation of health-care jobs."

Uh oh, Congress is between a rock and a hard place!

What, you ask, will Congress do?

Well, your crystal ball is as good as mine is.

But, today's Online News Hour with Jim Lehrer spoke truth to power when, in the face of massive US job layoffs, the show's moderators advocate spending in order to 'elevate demand in the economy'.

Right now, the 2 trillion dollar US health care economy is 50% funded by the US government.

One specific reccomendation of the moderators...

• Spending money now on Electronic Medical Records (EMR) - expected 10-year return (according to Congressional Budget Office)= $90 billion.

Another spending item that will no doubt surface in discussions is the The Medicare Access to Rehabilitation Services Act (H.R.43/S.46) sponsored by the following:

• Congressmen Xavier Becerra (D-CA)
  
• Mike Ross (D-AR)
  
• Roy Blunt (R-MO)
  
• Senator John Ensign (R-NV)

In 2009, the therapy cap is an easy target that physical therapists need to popularize for the benefit of our patients.

It may seem opportunistic to exploit political circumstances for economic gain now but physical therapists must remember that, for too long, the policy-makers in Washington have exploited physical therapy patients and providers for such morally ambiguous concepts like 'budget neutrality'.

Act now and contact your congresswoman (or man) and ask them to suport H.R. 43/S. 46 .

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.

"I just can't go on like this", she said.

Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"


2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"
   

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:

"...depression is rapidly becoming the second leading cause of disability in the world."

Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:

• sitting
  
• studying
  
• sleeping

...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

	ICF descriptor	ICF code
Body Functions
	Pain in Head and Neck	b28010
	Regulation of Emotion	b1521
	Psychomotor control (agitation)	b1470
Activities & Participation
	Maintaining a lying position	d4150
	Maintaining a sitting position	d4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.

The Audacity of Hope for Physical Therapists

Physical therapists may be able to take hope from new legislation in Congress that promises to outlaw physician ownership of hospitals on the premise that such arrangements are a conflict of interest.

The new legislation is attached to The Children's Health Insurance Program Reauthorization Act (SCHIP) as part of HR 2.

HR 2 passed 289 ayes to 139 nays in the House of Represenatives on January 14th, 2009. It's companion bill now goes to the Senate for consideration. The American Medical Association is lobbying against this bill on the basis that it limits physicians' rights.

Can legislation that prohibits physician ownership of physical therapy clinics (POPTs) be far behind?

One can only hope that the Obama administration is taking a hard look at POPTS not only as a conflict of interest but also as a cost-cutting measure to reform health care.

Is the OPTIMAL a subjective scale?

"It's a hurt but not a pain."

"My pain hurts when I stand at the counter to fix meals longer than five minutes."

"It gnaws and hurts and then I get angry because I can't do anything anymore!"

Physical therapists work with these folks every day.

You hear this every day.

Me, too.

Outpatient physical therapists working for Medicare are asked to quantify pain and activity limitation using baseline activity scales, such as the following:

• OPTIMAL
  
• FOTO
  
• AM-PAC
  

These scales, however, have typically been labeled as 'subjective' measures of patient function because patient self-report is not as reliable as a clinician's assessment.

Reliability is exactly the point when you see a side-by-side comparison of several traditional measures of patient illness and function.

Richard Deyo, MD originally presented data that I have reproduced here in this chart:

Reliability of Potential Outcome Measures for Back pain Trials
Type	Measure	Estimated reproducibility (test-retest correlations)
Laboratory	Spinal fluid endorphins
	Paraspinal EMG activity
Physical Measurements	Anterior spine flexion	0.50
	Passive straight leg raise	0.78
	Ankle dorsiflexion strength (dynamometer)	0.50
Function & symptoms	'Ability statements'	0.90
	Pain (VAS)	0.94

The reliability of the OPTIMAL scale is determined by a different method - a method more appropriate for studying difficulty or confidence. (Guccione et al)

OPTIMAL reliability
OPTIMAL	0.85 to 0.95

Note that the OPTIMAL is more objective than typical measures of physical function - the ones you and I learned in PT school.

Can we do better?

Sure.

As we've noted elsewhere on this blog, the OPTIMAL is a political and a policy compromise - not an academic or a clinical superstar.

But, in my opinion, using the OPTIMAL facilitates an improvement in physical therapists clinical decisions and, perhaps, the notes we write.

Since 60% of physical therapists probably don't use baseline outcome measures (Copeland, PTJ Dec. 2008) the OPTIMAL represents a 100% improvement.

The Medicare Minimum Documentation Requirements (Transmittal 88) states...

"If results of one of the ...instruments (OPTIMAL, FOTO, AM-PAC) above is not recorded, the record shall contain instead the following information..."

1. Identification of other health services concurrently being provided for this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse, respiratory therapy, social services, psychology, nutritional/dietetic services, radiation therapy, chemotherapy, etc.), and/ or


2. Identification of durable medical equipment needed for this condition, and/or


3. Identification of the number of medications the beneficiary is talking (and type if known); and/or


4. If complicating factors (complexities) affect treatment, describe why or how. For example: Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient, but in some patients such dysrhythmias may so directly and significantly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services. Documentation should indicate how the progress was affected by the complexity. Or, the severity of the patient’s condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated; and/or


5. Generalized or multiple conditions. The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated, or generalized musculoskeletal conditions, or conditions affecting multiple sites and these conditions will directly and significantly impact the rate of recovery; and/or.


6. Mental or cognitive disorder. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.


7. Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.

Yes, OPTIMAL measures a subjective experience...

"My leg hurts - it burns to the ankle and I can't walk!"

But OPTIMAL is an objective measure of a subjective experience - and it's helped me help my patients more.

The Medicare Taxonomy for Physical Therapists

I am not a doctor.

I don't even play one on T.V.

I don't have a Ph.D.

I don't have a Doctor of Physical Therapy (DPT).

I'm a physical therapist (PT).

That's it.

And, I present material in this blog that some people may associate with post-graduate instruction, legal advice or consulting on Medicare compliance.

That would be a mistake.

All I do is treat patients with physical therapy, write my notes and try to understand our nation's Medicare program as it applies to outpatient physical therapy services.

To help the process of Medicare compliance I created my alternate website, Bulletproof Physical Therapy Notes and Charts with free government and professional resources on making a do-it-yourself Medicare compliance program.

Isn't that the way most physical therapists are?

Resourceful?

Ultimately, I intend to create a taxonomy that students and non-professionals can use to understand the work we physical therapists do for our Medicare patients.

It's crazy that I can describe Medicare with taxonomy, a word originally used to describe the complexity of living organisms.

Now, Medicare compliance is completely the jurisdiction of "Medicare auditors"

• un-elected


• un-licensed (as auditors)


• non-peer reviewed

..."experts" that get paid to look at your notes.

Don't get me wrong - everybody deserves a chance to make a living - even Medicare auditors.

The $3 billion Medicare program needs auditors - to catch the bad guys.

That $3 billion attracts a lot of bad guys.

But, physical therapists usually aren't bad guys (or girls).

What physical therapists need is a simpler, less intimidating process to...

• document our findings
  
• show medical necessity
  
• show progress
  
• show skilled decisions
  
• help patients without taking ridiculous risks
  

Am I the only one who thinks this way?

I answered a question today on the Yahoo Groups PT Manager list-serve.

Hello Group,

I am looking for any information or suggestions on Treatment Diagnoses vs. Medical Diagnoses. I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

New Grad

******************

Dear New Grad,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

...to be treated with the following...

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the health care market.

Tim

Medicare Compliance through Physical Therapist Competence

I got feedback on a post today on the Yahoo Groups PT Manager list-serve.

I thought the post might be worth re-posting.
(note: this is not original content - I wrote the answer 6 hours ago for another site).

QUESTION:

I am looking for any information or suggestions on Treatment
Diagnoses vs. Medical Diagnoses.

I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

XXXXXXX, PT

ANSWER:

Dear XXXXXXX,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

...to be treated with the following...

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the care market.

Tim Richardson, PT
www.BulletproofPT.com
'Compliance through Competence'

Do You Understand Physical Therapy?

"Do you understand?"

"Does that make sense?"

You might think I'm asking you about Obama's new health care plan.

I'm really showing you how I speak to my physical therapy patients every day as I explain their diagnosis and ask for their 'buy-in' for their plan of care.

What I'm actually doing is asking many of my patients to make commitments to lifestyle changes that take their money, attention and time.

Patients with arthritis, hip replacement surgeries, sports injuries and car accident victims all depend on an accurate physical therapists' diagnosis.

Head nods are nice but I need commitment to get patients to adhere to their home exercises.

I'm asking my patients to commit to action-plans that I have made based on my decisions in my physical therapy diagnosis.


What's a Physical Therapy Diagnosis?

Doesn't the doctor do that?

The doctor makes the diagnosis, orders therapy and the therapist follows the orders, right?

Maybe.

What if the diagnosis is "Low Back Pain" (a symptom, not a diagosis) and the orders are "Evaluate and treat"?

Then the physical therapist needs to make a decision.

The physical therapist needs to make a diagnosis.


Different than the Doctor?

The physical therapist may arrive at her decision differently than the doctor.

Ian Edwards, an Australian physical therapist, studied clinical reasoning strategies in physical therapists.

Clinical reasoning strategies are...

"...a way of thinking and taking action within clinical practice."

Edwards was able to divide reasoning strategies into two groups:

1. Diagnosis


2. Management

Diagnosis was further divided into two groups:

1. Diagnostic reasoning - linking physical impairments to disability (see the ICF model)


2. Narrative reasoning - listening to patient 'stories', beliefs and cultures.

Management was divided into six groups:

1. Reasoning about procedure - selecting interventions.


2. Interactive reasoning - establishing patient-therapist rapport.


3. Collaborative reasoning - setting patient goals and progression of activities based on consensus.


4. Reasoning about teaching - assessing the patient's receptivity to and understanding of the therapist's findings.


5. Predictive reasoning - 'envisioning future scenarios with patients', eg: getting better.


6. Ethical reasoning - ethical and practical barriers to achieving all of the patient's goals.

What's the point?

Physical therapist decision-making can also be divided based on its intended purpose:

1. Treatment


2. Documentation

Physical therapists, I believe, treat their patients using the following of Edward's reasoning strategies:

• Narrative reasoning


• Interactive reasoning


• Collaborative reasoning


• Reasoning about teaching

Physical therapists document their findings and write their notes and charts using the following of Edward's reasoning strategies:

• Diagnostic reasoning


• Reasoning about procedure


• Predictive reasoning


• Ethical reasoning

The physical therapist's diagnosis is important for the patient's final outcome. Make the wrong diagnosis and the patient doesn't get better.

The physical therapist's notes and charts are important for legal and audit protection, accurate reimbursement, peer communication and patient progress.

Make the wrong decision while writing in the chart and the therapist doesn't get paid, or worse.

Do you understand?

Does that make sense?

Computer costs for physical therapy falling

Physical therapy computer costs are falling. Mine especially.

This article from CNN Money talks about the Obama stimulus plan and the huge expense of training the labor force to implement a computerized health infrastructure.

$100 billion of the $800 billion Obama stimulus plan is proposed to be spent on making all health records standard and electronic by 2014.

17% of physicians and physical therapists now use electronic medical records. 8% of all hospitals use them.

We started a new electronic medical records system last week at Medical Arts Rehabilitation, Inc. in Manatee County, Florida.

Costs have really come down.

The first system I priced two years ago was $60,000 and I would have had to buy two servers to host it all.

The system I bought in December 2008 cost $4,800 and we are up and running in two weeks. It's called Clinic Controller by A2C Medical.

I'll blog my results regularly to keep the physical therapy community updated on our efforts.

We set it up ourselves (I paid an IT guy 2 thousand to configure the system and set the backups - I think I overpaid).

Now, I'm building templates of my

1. Evaluation


2. Progress Notes


3. Daily Notes


4. Re-certification Notes


5. Superbill


6. Patient schedule/calendar

The system is quick and intuitive.

I'm sure I haven't seen the glitches yet or the workarounds that inevitably come with any mechanical device but we're better off than we were with our old DOS-based system (yes, DOS).

We are running both systems in tandem for the time being.

Today, we shut down the old scheduling system but we still have to collect money and post accounts to the old system, probably for three-to-six more months.

I wont see any increase in revenue by switching but I guess I'm getting ready for the new health care infrastructure from the Obama administration.

I figure we'll have our new computers running smoothly before Obama has fixed the health care system.

Faith and Physical Therapy

Today is Sunday, the 11th of January and faith is on on my mind.

"Now faith is the substance of things hoped for, the evidence of things not seen."
Hebrews 11:1

My first job in 1992 had me working with Mike, a physical therapist who would pray with his patients.

At the time I had no religion training and I didn't know quite what to make of Mike's non-traditional efforts to care for his patients.

Mike didn't pray with every patient, just those that seemed receptive and who needed that extra bit of inspiration to keep going and get better.

In 1992 neither Mike nor I had much knowledge of Medicare payment policy and so he would bill the patient for his time spent in prayer.

Today, of course, I realize that since prayer doesn't meet the criteria for physical therapy skilled services it shouldn't be paid for by Medicare or any third-party payer.

I tell this story because in 2006, Medicare spent $3.06 billion dollars on outpatient physical therapy services with no evidence that the services were any more skilled than Mike's prayer.

Now, maybe we all need a bit more prayer. I certainly pray more now than I did in 1992.

But, when we are talking about evidence of skilled decisions, we need to provide evidence that physical therapists' decisions matter.

Otherwise, we are no better (and no worse) than...

• massage therapists
• athletic trainers
• personal trainers
• 'kinesiotherapists'

...we are just more expensive.

Current efforts to improve physical therapists' decision-making tools come from several sources...

1. The Physician Quality Reporting Initiative (PQRI) - a much lambasted project begun in July 2007 to measure performance among healthcare providers. The project is cuurently establishing a baseline of over 100 variables that will gauge the health and function of Americans on such measures as falls risk, medication usage, pain, incidence of diabetic foot, body mass index and more.


2. Developing Outpatient Therapy Payment Alternatives (DOTPA) - kicked off in September 2007 with data collection set to begin in May 2009 this project aims to reduce the impact on setting (eg: home health, outpatient clinic, hospital) as a driver of payment.

The DOTPA project plans to develop two pen-and-paper outcome measures based on ambulatory status (walking and non-walking). The universal use of these outcomes measures will enable an 'apples-to-apples' comparison of patient outcomes across various settings.


3. OPTIMAL scale is one of the current professional consensus, Medicare-recommended outcomes tools for outpatient physical therapy. OPTIMAL is a broad outcomes measure that will enable the aformentioned 'apples-to-apples' comparisons.
   
   OPTIMAL is meant to be paired with a condition/disease specific measure such as the Lower Extremity Functional Scale, the Neck or Back Disability Index, etc.
   
   Yes, that means you may need to administer two seperate outcome scales to each patient.
   
   Other professional consensus, Medicare-recommended outcome tools are the Activity Measure for Post Acute Care (AM-PAC) and the Focus on Therapeutic Outcomes (FOTO)


4. The American Physical Therapy Association (APTA) provides continuing education on Medical Necessity and Medicare payment policy on a regular and convenient schedule.
   
   An encyclopedic resource on documenting skilled physical therapy services is the APTA's Defensible Documentation for Patient/Client Management


5. The Diagnosis Dialogs that are attempting to find descriptors (or labels) for physical therapists to describe the results of our clinical examination and evaluation. The descriptors/lables would be...
   

   "standardized anatomical, physiological or functional terms that concisely describe the condition or syndrome of the human movement system."

6. Edward's decison-making model shows how physical therapists decisions (and diagnoses) are different, complementary and equally important with physicans' diagnoses.


7. Bulletproof Physical Therapy Notes and Charts is my own effort to improve written decision-making through what I call competency-based compliance, that is, the intersection of evidence-based practice with Medicare payment policy.
   
   I've been working on Bulletproof for about two years and I have a book due out Summer 2009.

I haven't seen Mike in 10 years and I don't normally pray with my patients. I'm glad, however, that he showed me his example of patient care.

He showed me that his care, by his prayer, could be distinguished from his skill.

Hopefully, all physical therapists have stories of our care that may not show up on paper. There may be no evidence.

"Faith proves to the mind, the reality of things that cannot be seen by the bodily eye."

But now, we have new tools that can show our skill. We can justify the next $3 billion dollars spent on outpatient physical therapy. We can have evidence of the things we see in physical therapy.

What are your stories?

A physical therapist can remember when $650 billion was a lot of money for health care

Hearing about health care reform in the news all day long, I felt compelled to educate myself about some of the facts.

I turned to a trusted source, McKinsey & Company, to understand how all the pieces fit together.

Accessing this slide show may require a free subscription.

The 17-slide Flash demonstration tries to explain why the US spends $650 billion more than expected (compared to peer-nations) even though our disease prevalence is lower than average.

I can remember when $650 billion was a lot of money.

Key points:

• Most (2/3) of the $650 billion is spent on outpatient care, which more than offsets increased utilization by improved cost-effectiveness over inpatient and long-term care.


• US health administration costs are 5 times higher than peer average.


• Our multi-state regulatory system creates inefficiencies and waste.


• Public spending (Medicare et al) accounts for almost 50% of total spending.


• Private spending only accounts for 13% of total spending.


• Private payer reimbursement grows when Medicare price growth slows.

My takeaway from this centers on the next-to-the last point, the out-of-pocket (OOP) expense (at 13%).

How can private spending be expected to grow (think...

• larger co-pays,
  
• alternative medicine,
  
• cash-based physical therapy practices.)

...when comparable OOPs, like Japan, for instance, are in the 2-3% range?

The McKinsey report is sweet eye candy for the hardcore policy wonk but it's conclusion offers little that is new, different or hopeful for those of us with boots on the ground in the American health care trenches.

Physical therapists: Put your diagnosis in your goal

This extra step in your clinical thought process can dramatically improve your notes and charts for your Medicare compliance program.

The simple act of linking the measured impairment to the patients' activity limitation is one of the essential skilled components of physical therapist practice.

For example:

“Improve sidelying hip external rotation from 15cm to 25cm in order to improve OPTIMAL Balance from 4/5 to 2/5.”

Your clinical rationale is explicit in the goal – without the need for additional statements clarifying the link between measured impairments (hip external rotation) and patient activity limitations (balance).

Your physical therapy diagnosis may change from body part to body part and from activity to activity.

For example, the same patient may have the following goal:

“Improve AROM ankle dorsiflexion from 0 degrees to 10 degrees in order to improve OPTIMAL Stairclimbing from 4/5 to 2/5.”

Diagnosis differences

The interesting thing is that our diagnosis is not predicated on any medical model.

In the examples above, the written reason for patient referral was the following:

‘lumbar strain’ – ICD-9 code 722.93 (Other and unspecified disc disorder, lumbar region).

The physical therapist independently identified the two above mentioned areas above that needed attention that could not be consistently predicted by the medical diagnosis.

The ICF model, on the other hand, more accurately identifies the work and the decisions made by the physical therapist.

A physical therapist might diagnose, using these ICF codes, the activity limitations and impairments in body structure and function.

ICF Domain	ICF descriptor	ICF code
Activity	Walking on different surfaces	d4502
Body structure	Muscles of ankle and foot	s75022
Body function	Mobility of a single joint	b7100

Using a disablement model as the decision-making framework and making the commitment to always diagnose every patient the physical therapist is freed from the subservient, technical position in the medical model.

The physical therapist is put in the position of making decisions that are in the best interests of the patient, based on the finding from the physical therapy evaluation.

No other professionals are examining patients at this level:

• not physicians
  
• not chiropractors
  
• not massage therapists
  
• not athletic trainers.
  

Decision-making and the physical therapists’ diagnosis are the sustainable competitive advantage of physical therapy over all of these other professions in the care and rehabilitation of our patients.

Put your diagnosis in your goals to improve your written work.