Financial Evaluation and Treatment

How to fix the financial crisis...

...and help private practice physical therapists at the same time.

These recommendations by James K. Galbraith, a scholar at the University of Texas at Austin to the U.S. House of Representatives on February 26, 2009 make a lot of sense to a private practice physical therapist like me...

• a permanent increase in Social Security benefits would help offset the losses that the elderly population, as a group, is suffering on its equity investments and its cash holdings. A thirty percent increase in Social Security benefits would not repair individual losses, but it would keep the elderly out of poverty as a group, and relieve severe difficulties in many individual cases.


• a payroll tax holiday would powerfully ease the financial situation of America's working families, giving them roughly an 8.3 percent pay increase and their employers a comparable reduction in the cost of keeping them on the job. Many mortgages would be paid, and many cars purchased, that otherwise would default or go unsold.


• a reduction in the age of eligibility for Medicare would be a powerful response to the industrial crisis, permitting many older workers who would like to retire but who cannot afford to lose health insurance to do so. This would relieve health burdens from private industry, while not infringing on the employer-insurance systems still in effect for the prime-age workforce. Note that transferring workers from private health care to Medicare in this age bracket has no real economic cost: the same health care is provided to the same people. In fact, the reduction in private insurance claims and bookkeeping constitutes a real saving.

Read Point #4 to get Mr. Galbraith's preface and conclusion - better yet, read his whole speech.

Now, getting all of this done without raising taxes... Impossible?

Spanish OPTIMAL available for Physical Therapists

I like the OPTIMAL scale.

I use it enough to need a spanish translation - you can get a copy of it here (Links or Forms page).

Remember to request copyright permission from the APTA to use it in your clinic.

Like many things, it is not a perfect solution for outpatient physical therapists looking for outcome scales.

The shortcomings of the OPTIMAL are well-described here.

The best critique of the OPTIMAL is that better alternatives exist.

Like a 50-year old dowager waiting for perfect love the quest for 'the one' can leave us frustrated.

Since only 48% of physical therapists currently use outcomes measures it seems like many PTs are waiting for 'the one'. (PHYS THER 2009 89: 125-135)

This spanish version is not 'the one' but it may be a step closer to getting a majority of physical therapists to use outcome measures.

“If I could wish for my life to be perfect, it would be tempting but I would have to decline, for life would no longer teach me anything.”

- Allyson Jones

75-year old man runs marathon with 'bone-on-bone' arthritis

Just this weekend I attended the Running Conference at the University of Florida Orthopedics and Sports Medicine Institute in Gainesville.

There, one of the presenters claimed to have helped his patient, a 75 year-old runner, continue marathon training and racing despite Grade IV 'bone-on-bone' knee arthritis with bi-annual injections of hyaluronic acid (chicken cartilage) into the knee joint space.

Irrespective of testosterone-laden "atta-boys!" or of wry head-shaking at old ages' folly I still want to know this:

How was it paid for?

75 year-olds generally have Medicare.

Medicare usually pays for one course (3 or 5 injections) of viscosupplementation every six months in Florida.

Hyaluronic Acid (aka viscosupplementation) pays fairly well for the course of treatment: ~$250 for specialist surgeons and ~$150 for non-specialist physicians.

I, as a physical therapist, have to show that my 75 year-old patients need physical therapy to prevent progressive disablement, loss of independence or institutionalization.

For example, I can't say that one of my patient's goals is to...

1. Run a Marathon!

Marathon running is not "functional".

That is, racing marathons wont necessarily keep grandpa out of the old folks home.

Why (apparently) does Medicare pay orthopedic and sports medicine doctors to keep 75 year-olds running marathons when Medicare wont pay physical therapists to keep 75 year-olds running marathons.

Is there some evidence that chicken cartilage is more cost effective than physical therapy?

Physical therapists still get to decide!

I want you to get the message from this new Medicare Transmittal 1678.

It came out February 13th, 2009.

Scroll to 'page 9' - find the new text (usually in red).

Here you will find the following:

"There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline."

The Transmittal references the Computer Sciences Corporation (CSC) Therapy Cap Report and the Edit Tables.

What are these reports?

CSC mines Medicare data to help government analysts understand their own data.

Then, since you and I pay for this data, they make it public.

Transmittal 1678 is the first time Medicare has specifically referenced these CSC reports to give physical therapists guidance on how much therapy to give our patients!

For example, this table (zipped file) says that, on average, Physical Therapists in Private Practice (PTPP) charge four (4) Therapeutic Exercises every session and that the range is 4-6 units.

How much Therapeutic Exercise do you do? More? Less?

Wait!

Shouldn't the physical therapist decide, based on findings from the evaluation, how much therapy the patient needs?

Why are governement bean counters in green eyeshades deciding for physical therapists how much therapy to provide?

Because we let them.

You decide.

If you go over (or under) the statistical ranges in the CSC reports you need to show why your patient needs more (or less) than the average amount of therapy.

Why are you different?

Are you better?

If you are then show it! Say it! Measure it!

Use new measurement tools to show Medicare the numbers - they love numbers!

Use validated outcome measures to show need and progress.

Who gets physical therapy?

Physical therapy happens between your patient and you - not in Washington DC!

I want you to get the message - you decide.

A Blow to Autonomous Practice

How much therapy is enough?

Who decides? You?

Maybe not.

The recently published Transmittal 1678 (February 13, 2008) details resources you should use that...

"suggest the amount of certain (physical therapy) services that may be typical, either

• per service
• per episode
• per condition
• per discipline...

The resources are the following...

1. Computer Services Corporation (CSC) Therapy Cap Report, 3/21/2008
2. Computer Services Corporation (CSC) Therapy Edit Tables, 4/14/2008

To summarize:

One in eight physical therapy patients received a -KX modifier in 2006 ($1,740 capped amount).

Florida, New York and New Jersey were the three states with the highest percentage of therapy users over the cap.

These are the three most common physical therapy diagnoses billed to Medicare in 2006.

• 781.2 Abnormality of gait
  
• 724.2 Lumbago
  
• 719.7 Difficulty in walking
  

However, the diagnoses most likely to exceed the cap were different:

• 438.22 - Hemiplegia affecting nondominant side - 31.3%
  
• 438.21 - Hemiplegia affecting dominant side - 30.9%
  
• 438.0 - Cognitive deficits - 30.6%

"In other words, some beneficiaries with diagnoses, although less commonly observed, are more likely to surpass the cap threshold."

Only 2% of physical therapy users who exceeded their capped amounts accessed the hospital to continue their therapy.

Transmittal 1678 suggests that if your billing profile deviates much from these parameters then you may have some explaining to do.

Who wins?

CSC touts the therapy cap exception process as a win for patients (improved access) and for Medicare (lower costs).

Physical therapists, however, are micro-managed, clinical decision-making is aborted and financial risk is shifted to the provider.

Is this sustainable?

No.

Not without the use of financially-motivated third parties (RACS) that treat health care providers as a revenue source.

Drugs, Surgery or Physical Therapy?

Drugs, Surgery or Physical Therapy?

On February 17th the New England Journal Of Medicine spoke about the American Recovery and Reinvestment Act of 2009 ($787 billion economic stimulus package) in a column by Robert Steinbrook, M.D...

"On the medical research front, comparative effectiveness studies that directly compare the risks and benefits of different treatments for a particular condition are essential for improving practice and slowing cost escalation.

Such studies, however, have been controversial; the pharmaceutical and medical device industries may not fund them, and some are concerned that the government or insurers may use the results to mandate specific approaches to treatment or to deny coverage."

Pharmaceutical and Medical Device Industries wont pay?

Are they afraid of a side-by-side outcomes and cost-effectiveness comparison to physical therapy?

They are afraid of a mandate?

Should exercise or conservative care be mandated prior to spinal surgery for lower back pain?

The Act anticipates this concern by saying that the funds will not be spent to...

"mandate coverage, reimbursement, or other policies for any public or private payer."

Mandates or not, expect changes in health care policies and priorities from the sudden wave of money, most of which will be spent within two years.

"...the $1.1 billion in new funding for comparative effectiveness research dwarfs the current $334 million annual budget of the Agency for Healthcare Research and Quality."

But then, we should be used to change by now.

Are you?

Get 'Bulletproof' Physcial Therapist Decisions

Get a blueprint for Bulletproof Decision Making courtesy of the Orthopedic Section of the American Physical Therapy Association (APTA).

Full disclosure: Bulletproof Decision Making is an independent project and is not endorsed by the APTA or the Orthopedic Section.

One of the 'Brand Personalities' from APTA's new Move Forward branding campaign is...

"Completing flawless and thorough documentation to insurance companies"

How do we do that?

One way to get 'flawless and thorough documentation' is the new Hip Pain and Osteoarthritis Clinical Practice Guideline from the Orthopedic Section of the APTA.

This practice guideline is special in that it is the first guideline to include measures of Activity Limitations and Participation Restrictions.

So what?

Patients can 'self report' their activity limitations using a scale such as the OPTIMAL (eg: squatting).

The new hip guideline includes measures (eg: Functional Squat Test) that objectively measure these self-reported activity limitations.

The first two guidelines (heel pain and neck pain) do not include standardized activity and participation measures.

Some Medicare experts deride patient self-report scales (like the OPTIMAL).

They say the OPTIMAL is not objective.

I think it is.

Here is evidence that OPTIMAL is objective.

If you base your Medicare compliance program on the OPTIMAL (like I do) then you may want to prepare yourself.

The new hip guidelines give you better data about patient function and are consistent with the philosophy of Bulletproof Decisions.

I can't think of a better definition for Bulletproof than "flawless and thorough".

Can you?

Motion

Motion.

The new brand statement of physical therapy.

The package is slick, comprehensive (tone?) and stylish.

I like it, but...

Is motion a technique?

Not a decision?

I prefer to think that my special skill is physical therapist decision-making.

Massage therapists and athletic trainers can provide motion techniques.

Still, we need to own a piece of the consumers' mind in this competitive market.

Motion is where the consumer already positions physical therapists.

So, let's run with it.

Do you like it?

Half of Japanese Physical Therapy Practices are Insolvent

Insolvent.

In the red.

More liabilities than assets.

That's where Japanese medical providers (and physical therapists) are financially.

No, it's not due to the current financial crisis.

It's due to Japan's chronic under-spending on health care.

Spending on Health Care	...as a per cent of GDP
Japan	8%
US	16%
Medicare	8%
Note: Medicare pays for half of US health care consumption

The take home message is that US health care providers rely too much on Medicare.

Currently, most US health care providers are solvent.

However, a 21% cut in the Physicians' Fee Schedule on Jan 1, 2010 threatens the largest, quickest-paying revenue stream for many physical therapist private practices.

The Obama administration has affirmed its intent to embrace Electronic Medical Records (EMR) as a means of of cutting costs in the Medicare program.

What does that mean for physical therapists?

Medicare is desperately trying to cut costs before the wave of aging Baby Boomers washes over our heads and drowns us in red ink.

Can physical therapist private practices cut costs faster than Medicare cuts theirs?

Will electronic medical records help physical therapists cut costs?

What do you think?

Overheard at the CMS watercooler...

Overheard at the watercooler at the Centers for Medicare and Medicaid Services (CMS)...

Hmm,

In-person contact and proactive advice on exercise could reduce Medicare hospitalization and reduce costs, according to this February 11th JAMA article.

I wonder where we could get in-person contact and proactive advice on exercise?

Maybe using physical therapists as primary care providers would save money!

I couldn't hear the rest of the conversation between the CMS staffers but, as they walked back to their desks I heard one of them exclaim loudly,

"...this study offers ... important insights to guide Medicare policy on coordination of chronic disease care going forward.

“... care coordinators must interact in person with patients and not simply educate or assist them by telephone. Only 4 of the 15 programs emphasized in-person contact between coordinators and participants..."

I hope those staffers have some influence with their bosses - so physical therapists get better positioned to help our patients with exercise advice and save some money.

Would most physical therapists in the United States feel comfortable in a primary care role, giving advice to patients?

What do you think?

Medicare RACs attack

As noted across the blogosphere the Medicare Recovery Audit Contractors are aiming their guns at health care providers after a 4-month hiatus.

Their primary target is inpatient hospitals.

That's where the money is.

Witch Hunt?

The federal government sees health care providers as a revenue source.

RACs bid for the right to audit and collect overpayments from providers. The RACs then keep a portion of those overpayments.

Some say the rewards to the RACs could lead to over-aggressive collection efforts.

Do you think RACS are unfairly incentivized to target and collect overpayments?

Do you think physical therapists in private practice need to worry?

Physical Therapists and Physicians have something in common

Physical therapists and anesthesiologists have something in common.

Both professions have difficulty showing need for their services.

1. Exercise by physical therapists.
   
   
2. Facet joint injections by anesthesiologists and other physicians.

This report by the Office of the Inspector Generals' (OIG) indicates physicians have difficulty showing medical necessity for spinal facet joint injections.

Eight percent of the claims were paid despite no evidence (x-ray fluoroscopy) that the services were medically necessary. The overall paid claims error rate for facet joint injections was 63%.

Physicians use fluoroscopic imaging to demonstrate pathology necessary for medical diagnosis and treatment by facet joint injection.

However, the...

"...lack of consensus in the medical community about appropriate frequency of injections is a barrier to creating frequency limits in Local Coverage Determinations."

Thirteen of the 15 Medicare Carriers have Local Coverage Determinations that set forth medical necessity requirements for facet joint injections.

"Carriers are also responsible for implementing program safeguards to reduce payment errors. To accomplish this, carriers create local coverage determinations (LCD), issue instructional articles implement claims processing edits. Carriers also analyze data, conduct provider education, and conduct medical reviews."

An uncertain environment

Physical therapy medical necessity is even more ambiguous - for instance, there are no National or Local Coverage Determinations (LCD) that determine the criteria for physical therapy services like the following"

• Therapeutic Exercise (97110)
  
• Manual Therapy (97140)
  
• Neuromuscular Reeducation (97112)

Currently, the standard for physical therapy medical necessity is the 'expert opinion' of a Medicare auditor (who may or may not be a physical therapist).

The 'expert' reviews your written notes to see if the exercise codes you billed Medicare are necessary.

"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed." (Transmittal 88)

Can't physical therapy reporting get more transparent, less hazardous or both?

Why, when our focus is patient treatment, should we be forced to spend valuable patient time on lengthy notes and charts?

What does an outlier look like?

Well, this is a bit of a stretch even for TBC PT geeks...

What an outlier looks like...

Enjoy.

Tim

$100 Lumbar MRI in the USA?

Get a lumbar magnetic resonance image (MRI) for less than $100?

Is that possible?

In Japan, it is.

If the United States imports this feature of Japan's model in these changing health care times what implication does that hold for physical therapy?

$25 visits in outpatient physical therapy clinics?

Japan's system is called social insurance.

Japan is the world's second richest economy and, arguably, one of its most capitalistic.

Some other features of the Japanese system include the following:

• everyone is covered (rich people cannot 'opt-out').
  
  
• most care (80%) is provided by private doctors (not 'socialized medicine' like in Canada and England).
  
  
• no gatekeeper (you can see an allergist or orthopedic surgeon on your own).
  
  
• costs half as much as in the USA
  1. 8% of GDP in Japan
  2. 16% of GDP in the USA
  .
  
• Japanese people visit their doctor 3x as often as Americans do for simple procedures like blood pressure checks.
  
  
• insurance companies are non-profit and aren't allowed to 'cherry pick' - if you have a history of cancer they still have to insure you.
  
  
• zero medical bankruptcies.
  
  
• $280 per month health insurance premiums - and the employer pays half of that!

Will the Japanese model happen in the USA?

Should it?

What do you think?

The Freburger exercise study is good for physical therapy

The Freburger study is good news for physical therapists.

Exercise as a treatment for chronic neck and back pain - what a concept!

I live in the Tampa Bay area where many world-class spine surgery facilities promote their version of effective spine care.

I have seen criticisms of this study that are unwarranted.

The point is a high-profile, large study advocates the exercise approach to chronic LBP before surgery and that physical therapists are the most likely professional to recommend exercise.

"Exercise prescription provided by PTs appears to be most in line with current guidelines."

I am encouraged by these findings.

Anyone else think this is good news for physical therapists?

Is your physical therapy 'cookie cutter'?

I appears that a 'cookie cutter' approach to therapy services is not a unique problem to physical therapists.

This post by Kori E. Carson Dean, Ed.S states the problem of the 'one-size-fits-all' approach to therapy services as it applies to special education.

Apparently, Occuptional Therapy (OT) and special education services have 'rules, laws practices' that adhere to the philosophy of the Individuals with Disabilities Education Act.

These professionals also seem to approach professional autonomy in the same way that physical therapists approach the Doctor of Physical Therapy (DPT):

"The therapist is correct that a (medical) doctor cannot dictate the amount of service time the therapist is required to provide."

Since much of current physical therapy research is focusing on the question of classification and treatment group assignment I am inclined to ask:

"At what point do standardized 'treatment groups' become a 'cookie-cutter' approach?"

The Audacity of SOAP

SOAP notes hinder good physical therapy documentation.

SOAP notes began in the 1950's as part of the Problem Oriented Medical Record (POMR) for physician decision-making.

SOAP has been implicated by many authorities as hazardous to physical therapist decision-making.

Imagine this scenario: 

A big, fat hospital chart with specialty information: 

• internal medicine
  
• orthopedics
  
• cardiology
  
• gasteroenterology
  
• physical therapy
  

...all represented in one chart.

Clipped to the front of the chart is a single sheet of paper with the (in)famous acronym: S.O.A.P.

The doctor, whatever her specialty, needs to see the patient and do the following:

• establish the reason for the visit (S)
  
• take measurements (O)
  
• arrive at a medical diagnosis (A) and
  
• establish the plan of care (P)

Do physical therapists need to make these decisions - each visit?

*****

Do physical therapists make the same decisions as medical doctors?

SOAP hinders physical therapy notes because physical therapists make different decisions than medical doctors.

Daily, physical therapists need to assess and measure patients' activity and participation levels and make decisions based on the measurements.

For example...

"Today, I can't walk as far as yesterday because the bad weather has swollen my knee and hip joints"

Because her medical diagnosis is chronic knee osteoarthritis you decide to measure her knees and you find increased swelling, due to the weather.

You decide to alter her plan of care - instead of exercise today you want to use modalities.

You decide to recommend a cane, during the period the knees are swollen - to prevent falls.

Will your SOAP note support your decision-making?

Many authorities don't think so.

Is it time to ditch SOAP?

Do physical therapists need a proprietary clinical note-writing format?