Physical therapy in the Hollywood spotlight

Let's see if the 'bright lights' shine favorably on physical therapy.

Queen Latifah is signing on to play in a Hollywood movie about a physical therapist falling in love.

Queen Latifah has played some authoritative roles: Matron "Mama" Morton in 'Chicago' and Charlene Morton in 'Bringing Down the House'.

She seems likely to bring a strong voice to the role of a physical therapist helping to rehabilitate a basketball player.

The fact that the basketball player is her patient raises some concerns.

Let's hope the 'Cinderella tale' is a serious affair, and not a Tinseltown romp, where Queen Latifah's character considers carefully her professional responsibilities and legal liabilities when involving herself romantically with a patient.

Can we trust Hollywood?

C'mon!

What do you think?

Probably, physical therapists could organize a letter writing campaign to the producers of the new Queen Latifah movie (set to begin in May 2009) that would raise the issue of physical therapists professional responsibility.

Let's shine a bright light of our own in making this movie.

Health Information Technology: Salvation or Termination?

Terminator was a warning: a warning against technology, the government, big corporations and our own proclivity to self-destruction.

Terminator Salvation (#4) is due out in theaters 21 May 2009.

Why is a story about human-like, murderous robots relevant to physical therapists and health information technology (HIT)?

Maybe because health care is the biggest part of the US economy that has resisted innovations in electronic communication and information organization.

Yet machines are increasingly all around us and are becoming more and more parts of our lives.

We willingly adopt machine conveniences that make our lives more and more electronic (like this blog).

Are we afraid?

Are we resistant to embrace electronic communication, data storage and retrieval because the act of using a computer takes us away from face-to-face patient care?

No.

The main reason hospitals and health care providers don't adopt HIT is because of the cost. Health information systems can cost hospitals between $20 million and $100 million dollars.

Only 2% of hospitals, mainly urban, have adopted HIT according to a new study in the March 26 online edition of the New England Journal of Medicine.

“HIT adoption levels are abysmally low in American hospitals.

We have a long way to go to achieve a health care system that is fully electronic,” says lead author Ashish Jha, M.D., an associate professor at the Harvard School of Public Health.

The Terminator is a gory story but the health care dollars are real.

Another reason is complexity.

Health care regulations already overwhelm providers in even the most complex specialties - never mind that general physician practice may be more complicated than neurosurgery.

Whose side are you on: Humans or Machines?

"There is no fate but what we make" - John Conner

I am in the camp that believes automating and standardizing certain aspects of our craft:

• compliance
  
• documentation
  
• checklists for the following:
1. medication list
   
2. falls history
• home exercise videos hosted for free on YouTube

...would enable us to more fully engage and treat our physical therapy patient in the limited time that we have together.

The future of technology should not be about fear and fighting over who will pay for it - ultimately, we all pay for it.

Physical therapists can usher in and lead a new generation of health care providers by learning and using readily available (and often FREE!) tools available on the Internet.

I ran across this pithy quote from James Cameron, the director of the first two Terminator movies, in the April 2009 Wired magazine.

"(Terminator is)...about us fighting our own tendency toward dehumanization. When a cop has no compassion, when a (psychologist) has no empathy, they've become machines in human form.

Technology is changing the whole fabric of social interaction. We're absorbing our machines in a symbiotic way, evolving to become one with our own devices, and that's going to continue indefinitely."

Justify your Physical Therapy

How do you 'justify' your physical therapy?

How do you 'prove' that your patient needs physical therapy and is benefiting from your care.

Many physical therapists think that the patients verbal statements "I feel better!" placed in the written chart is sufficient to justify services to Medicare patients.

Many therapists use a simple outcome measure to show progress and demonstrate need.

Is one simple outcomes measure and patient "subjective" statements sufficient to exceed the $1,840 therapy cap?

Probably not.

Centers for Medicare and Medicaid (CMS) Transmittal 88 states the following:

"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."(p.23)

A narrative is a statement that says "Here is why I am putting the '-KX' modifier on my charges - here is why I think my patient qualifies for Medicare Part B benefits over the therapy cap."

A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. (p.24)"

If the record justifies...

That is a big IF...

This Justification Statement is the one my facility uses to PROVE our patient deserves their rightful Medicare benefits.

It also protects me from unfair fines or repayments if I get audited.

Disclaimer: I am a physical therapist in private practice - not a Medicare auditor. You should make your own decision as to the veracity of my statements and the extent to which my recommendations fit with your own compliance program.
I do not give individual compliance advice.

Note in the Justification Statement how various levels of clinical evidence support and reinforce each other:

• outcomes measures
• performance measures
• impairment measures
• written patient statements

"Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus." (p.26)

Your patients deserve the therapy they need.

Some facilities automatically discontinue physical therapy when allowed charges hit $1,840 - regardless of whether patient goals are met.

Is that fair?

A better way to save money

This is not my idea but it's worth repeating.

I first read about physical therapists being the 'gatekeeper' for high-volume, high-cost conditions like Lower Back Pain at MyPhysicalTherapySpace.com so I thought I'd use this blog to relay the message.

Let's see if it gets any traction.

You can help also.

Comment on this blog to improve its page rank or send your own ideas to Washington DC. President Obama is looking for a few good ideas here.

The Status Quo

This image is from Better Ways to Pay for Healthcare by the Network for Regional Healthcare Improvement and the Robert Wood Johnson Foundation.

This image dichotomizes cost into performance risk and insurance risk.

Medical providers should only have to worry about performance risk.

'Fee for Service' is in yellow - this is the status quo and it is dominated by physicians - good luck getting any traction there.

A Better Way

The 'Episode of Care' is where I think physical therapists would be adept at saving money and improving outcomes.

Presently, the episode of care for all diagnoses is only loosely organized by family physicians and other 'gatekeepers'.

'John' (from MyPhysicalTherapySpace.com) recommends this:

"...President Obama should appoint physical therapists as the nation's designated 'babysitter' for patients with musculoskeletal conditions.

In other words, our only role is to shield patients from the black hole of useless (and likely harmful) medical spend(ing)."

The Episode of Care is therefore based entirely on the Medical Model - patients come to us primed with MRIs and X-rays that trumpet their pathology and deflate the restorative power of physical therapy.


Physical therapists could intervene early, using the ICF/biopsychosocial model rather than the medical model.

I make the case for physical therapists manging the care of a lady who can't kneel down in the March 23rd PTD.

The Last Word

The third alternative payment model, Condition Specific Capitation would likely be managed by a large health system or hospital that looked at overall costs.

Can physical therapy show cost reductions for common, high-cost musculoskeletal conditions over an episode-of-care when PTs, instead of physicians, make the initial decisions for patient triage?

If so, then can we take responsibility for ALL the performance risk?

The Episode of Care that Cost More

Miss Edy still can't kneel down.

She told me today in physical therapy.

Miss Edy has been a physical therapy patient before for short courses of PT that have, thus far, ended with a surgical procedure.

She has, at various times, received therapy for her right hip, knee, low back and neck.

In that time span, she has had her right hip replaced and has had rods-and-screws implanted in her spine.

Her complaint was always right knee pain and an inability to kneel.

She never had hip pain.

She never had back pain.

She can kneel on her left.

Pathology Persuades

Miss Edy is convinced that her surgeons did a great job on her hip and back but she is perplexed why she cannot kneel on her right.

Kneeling is a skill.

Kneeling can be taught.

Physical therapists often need to ask their patients , specifically,

"Can you kneel?"

The OPTIMAL scale specifically asks patients, "Can you kneel?".

Did Physical Therapy Fail Miss Edy?

Why did each of Miss Edy's courses of PT end in surgery?

Did the surgeons, armed with her impressive MRIs, push the surgical option too hard?

In our fee-for-service system, they had every incentive to do so.

Did Miss Edy have too much faith in technology?

Did she have low self-efficacy?

In Search of a Better Model

I have taught students and new graduates the importance making decisions by the rehabilitative model instead of the medical model.

Sometimes I get blank looks.

Sometimes I get rolling eyes.

Sometimes I get "Tim, it's just too theoretical for daily decision-making!"

But, when I still hear physical therapists saying "We need to put a little ultrasound on your shoulder for the tendinitis", I know they have abdicated their diagnostic decision-making in favor of the physician's diagnosis.


Patients hear enough of that - they need to hear a unified message of hope from physical therapists.

"You can do it!"

An Epiphany

I was never taught a disablement model. I graduated from PT school in 1992 and I learned about Nagi in 2001 when the Guide to Physical Therapist Practice was delivered to my doorstep like an extra phone book.

I dutifully read it.

I learned about Nagi's framework which has since segued into the ICF framework seen above.

How do PT decisions relate to Miss Edy and the cost of her episode of care?

I wonder if the entire episode were managed with her chief complaint in mind?

"I can't kneel down."

How much would it cost?

Would she have been saved from two major surgeries?

This image shows the payment model that distinguishes between our current system and some alternatives:

• fee-for-service (yellow)
  
• episode of care
  
• Condition-specific capitation (aka: risk-adjusted global fees)

Get the Report here and view some physical therapists discussing the alternatives here.

$100,000 dollars later, Miss Edy still can't kneel down - but now we're working on it.

United 'fired' by physical therapist

I 'fired' United Health Care today.

United is the lowest paying insurance company in America,  for many physical therapist private practices like mine.

We kept United for many years mainly because their members are my friends, neighbors and fellow small business persons in my community.

Two years ago United paid me $40 per patient per day.

I was able to keep my doors open because I "cross subsidized" (APTA-Members Only) my friends, neighbors and fellow small business persons who were on United with higher-paying Medicare patients.

I had to fire United because, since early 2008, my average payment per patient has declined even though my patient volumes are up (+7.6% February 2009).

The reason is Medicare Advantage.

Medicare Advantage pays just as poorly as United.

Medicare Advantage has, since 2008, decimated my high-margin, high-volume Medicare caseload by transferring these patients to insurance plans that pay, on average, about 60-65% of traditional Medicare.

Funny thing, the US government pays Medicare Advantage $1.30 for every dollar CMS spends on traditional Medicare.

Today, President Obama said that the US could not afford to continue to support the Medicare Advantage program in his Town Hall speech from Costa Mesa, California.

When I wrote United to opt-out of my contract they quickly called me back to offer $60 per visit because I do such a "good job controlling utilization".

Maybe you can try this tactic to your advantage - if you still haven't fired United.

Medicare Recovery Audit Contractors (RACs) have, in 2009, begun their work auditing the charts and notes of hospitals, physicians and physical therapists.

Their activities have, as they impact physical therapists, have been discussed in this blog, also here, and here.

During the Medicare RAC Demonstration Project inpatient hospitals were the primary target, accounting for over 84% of the recovered amounts.

Physicians (and physical therapists) accounted for less than $19 million of almost a billion dollars recovered.

Will the same experience prevail with the Permanent RAC Program?

The American Association of Family Practices has prepared this Questions and Answers page that may help private practice physical therapists calculate their risk and answer their questions.

Do you make doctor-level decisions?

One of the missions of this blog is to help physical therapists make better decisions diagnosing and treating your patients.

Physical therapists aim to be doctor-level decision makers but what are the differences in how physicians and physical therapists decide?

Are there similarities, too?

What are they?

This chart shows the process physicians use to decide which Evaluation and Management (E/M) code to bill.

There are three components to the physician encounter used in decision-making:

1. History
   
2. Examination
   
3. Medical Decision Making

Note that physical therapists use this same process in the initial evaluation.

History is composed of...

1. History of Present Illness
• location
  
• severity
  
• timing
  
• et al...
  
2. Review of Systems
• constitutional
  
• musculoskeletal
  
• neurological
3. Past Medical, Family and Social History

Same old, same old

So far, you and I do this every day, right?

The Examination

The examination focuses on Body Areas and Organ Systems - the more the physician examines the higher she can code.

Physical therapists usually examine back (spine), extremities, neck, maybe the abdominal body areas.

We examine 'cardio', 'musculo', skin, 'neuro', 'resp' and constitutional organ systems.

Physicians examine more areas and systems than do physical therapists and can perform 'detailed' or 'comprehensive' examinations in this part of the process.

Medical Decision Making

Three 'grids'are presented:

1. Number of diagnoses or treatment options
   
2. Amount and/or complexity of data reviewed
   
3. Risk of complications and/or morbidity or mortality

Physical therapists consider many treatment options and possible diagnoses but our limited ability to order sensitive testing and further diagnostic procedures hampers our scores on these grids - in my opinion.

Show Time

I used a 'typical' physical therapy LBP patient and went through the process - answering the questions physicians have to answer for each new (or established) patient.

History	Detailed
Examination	Expanded, problem-focused
Medical Decision Making	Moderately complex

Additionally, 'face-to-face time' may be used to determine the level of service.

One-on-one anyone?

Take Home Message

Many physical therapy lumbar evaluations may qualify for a Level 3 or 4 E/M code, if physical therapists were allowed to bill like physicians.

Take a look for yourself - do you make doctor-level decisions?

Compliance and competence

Physical therapists wrestle with clinical competence the way teenage girls look at themselves in the mirror and ask...

"Am I pretty enough?"

Newly graduated physical therapists come armed with knowledge of tests and measures that can answer painful clinical questions and help patients get better, quicker.

We have available free resources - outcomes scales like OPTIMAL, DASH and LEFS that only 48% of us use...

We use validated and reliable performance tests (video) that predict function, such as future falls risk.

Yet we follow-up graduation with an often mad-cap rush to consume various 'flavors' of physical therapy techniques that promise to get the patient better and help us answer the question...

"Am I good enough?"

A new study in PT Journal found that physical therapists in the Netherlands preferred 'homegrown' methods of assessing, treating and diagnosing patients in place of government sponsored 'Guidelines'.

Compliance through competence

I am a big fan of standardization and EBP in physical therapy and I'd like to see more of it in clinical practice.

What I'd also like to see more of is a mindset that Medicare compliance should not be dictated to physical therapists by a self-annointed group of 'Medicare expert/auditors' whose livelihood comes from selling annual updates to physical therapists in the forms of seminars and webinars.

Where is that 'homegrown', self-sufficiency when it comes to Medicare compliance?

When will physical therapists find an innovative, cost-effective way to measure Medicare compliance the way we measure outcomes, performance and impairments in patients?

When will we take back our practice from the 'green eyeshades' in Washington DC who want physical therapy in 8-minute chunks?

What's the matter?

"Aren't we smart enough?"

'Fancy Theory' in Physical Therapy

Outpatient physical therapists don't often deal with life and death issues.

We may help patients with...

• back and neck pain
  
• walking difficulty
  
• stiffness
  
• sports injuries
  
• balance problems

...to name a few.

We make decisions, however, that affect patients' quality of life based on their self-reported activity limitations and their performance on standardized tests and measures.

That's why I was surprised day-before-yesterday (March 5th) when I gave a presentation to a class of Physical Therapist Assistant students and I mentioned the International Classification of Functioning (ICF).

I described the ICF disablement model as THE most important decision-making tool in my practice.



I got some blank stares.

I have heard other, experienced physical therapists describe disablement models as "too theoretical" for day-to-day decision-making.

Physical therapists' decisions are often made independent of the physicians' diagnosis and may not immediately impact a patients' pain.

This is where the ICF helps me.

Diagnosis and Prognosis

The physician may send the patient with a request for ultrasound (a technique).

The patient may show up in my office expecting a massage.

I may examine the patient and find the underlying cause of her dysfunction and decide that ultrasound and massage are irrelevant to the patient's long term goals.

For example, I examined a marathon runner this week with left lumbar and hip pain at rest and right knee pain while running. Previous treatments had focused palliative modalities on the left hip region. My examination found a stiff right hip (non-painful) and lumbar hypermobility.

I treated the right hip, explained to her why right knee ultrasound and lumbar massage would not be expected to help and asked her to return Friday.

She was quite a bit better and is running a 5k on Saturday.

My physical therapist assistant students listened intently to my story and jotted down the reference for review of the ICF.

Is it just me?

I came upon disablement models later in my career (2001) and I am still impressed with their elegance.

They have simplified my day-to-day decision-making and clarified my treatments.

My mission is to train PTs and PTAs to explicitly use the ICF to make decisions.

It's not just another fancy theory.

Hopefully new grads and students, with training that I never had, will segue into their careers using disablement models as a matter of course to improve patients quality of life.

It's not life or death but the ICF does make a difference.

Does anybody want to speculate what this baby is going to look like?

The following industry and trade groups were represented at President Barack Obama's one-day White house forum of changing health care in America.

1. AARP
   
   
2. National Federation of Independent Business
   
   
3. National Federation of Independent Business
   
   
4. Service Employees International Union
   
   
5. American Medical Association
   
   
6. American Hospital Association
   
   
7. Pharmaceutical Research and Manufacturers of America
   
   
8. America's Health Insurance Plans
   

Where was physical therapy?

Where were the physical therapists?

Is Medicare compliance related to clinical competence?

Bulletproof Decision Making started out as my own professional exploration of Medicare chart compliance for my private practice physical therapy clinic.

(note: you can sign up for Bulletproof at the bottom of this page)

I wanted to make a better compliance plan for my Medicare charts and notes.

My starting assumption was that good clinical documentation is completely related to competent clinical decision-making.

It is not.

Good clinical documentation today (2009) is all about dotting your 'i' s and crossing your 't' s.

What I learned

In early 2009, I paid a Medicare auditor $1,000 to come in and examine my charts and comment upon my compliance program. As you might expect, the auditor was able to find many 'deficiencies' in my charts.

I realized then that, to be helpful to other private practice therapists, Bulletproof needed to be about physical therapists' decisions driving treatment, documentation and compliance.

Why do physical therapists' decisions matter to Medicare?

Within a few short years, physical therapists may track their patient outcomes using remote data-gathering technology such as e-mail, web-based forms and CAT testing.

Patients could enter their own data.

This should reduce the 'information asymmetry' that has led some insurers to refer to physical therapy as a 'black hole' into which money disappears.

Currently, 52% of physical therapists do not use outcome measures which means that payers have no information showing if their beneficiaries got better, or not.

Electronic, standardized outcome measures will provide information on patient functional progress as well as initial and ongoing medical necessity for physical therapy.

Who are the Doctors?

Expansion of physical therapists' ability to serve as front-line health care providers means that the complexity of physical therapists decisions will determine the extent and intensity to which those services can be billed.

Physical therapists will bill like physicians.

Currently, physicians use Evaluation and Management codes (E/M) , that one day I hope physical therapists will use.

Payment to physicians is based on the following:

• an extended patient history
  
• detailed, multi-systems exam
  
• number of diagnoses
  
• complexity of decision-making
  

How do compliance and competence relate to each other?

Bulletproof is a resource that prepares physical therapists for the day when our decisions drive practice: when the frequency, intensity and need for physical therapy are derived from our physical therapy diagnosis.

The duration of physical therapy will be derived from the physical therapy prognosis.

I eagerly await the day when a Medicare audit of my charts is based, not on my handwriting or my chart templates, but on my decisions and on my clinical competence.