Psst! Wanna see an Episode of Care payment for physical therapists?

How would you like to solve the health care crisis?

Yes?

Well, you might get your chance. It's called the Episode of Care and its coming to your town soon.

I've spoken about the Episode of Care before on this blog.

In theory, the Episode of Care sounds neat and tidy.

In fact, the Episode of Care is messy and scary.

The American Physical Therapy Association (APTA) has some serious concerns about a 'post-acute care bundling policy' that bundles all payments for a basket of defined health services, like inpatient, surgery, imaging, lab, PT and skilled nursing, into one payment.

The Episode of Care has a 'risk chain' that passes risk down to the last provider on the chain.

Provider	Cost/Payment	Risk
US Gov't/Medicare	$18-26 billion	rising per capita health costs
Acute Care Hospitals	Episode of Care payment	re-hospitalizations
Rehab Agency, PTPP, CORF, SNF	Case Rate	'Outliers' with chronic and psychosocial conditions (eg: LBP, depression & anxiety)

The APTA, in a Statement for the Record to Senator Max Baucus(D-MT), recommended that any health care reforms...

"...implement programs that include care coordination payments for patients with high-cost, chronic illnesses..."

Psst!

Wanna know what an Episode of Care payment looks like?

Episode Level	Payment
Level 1	$55
Level 2	$135
Level 3	$225
Level 4	$300
Level 5	$530

Remember, you take on the risk that the patient, instead of the average 8-10 visits to PT, goes 40-50 visits.

Oh, and by the way, higher episode levels are based on prior surgery within 30 days, not true drivers of chronicity like elevated fear-avoidance beliefs and depression.

Most initial episode levels come in at a Level 2 ($135).

Is it just me?

I don't know - I may have some difficulty solving the health care crisis on $135.

Oh, and by the way, if you're curious where I got the data on episode levels just send me an e-mail.

I may pick your brain on how to solve the health care crisis in PT, as well.

Physical Therapists: Ready for some Risk?

Manatee Memorial Hospital - an acute care hospital at risk

Medicare wants to push $26 billion dollars in risk onto America's private health care providers.

Are you ready?

The timeline is 2010 - just over six months from now.

The risk is in managing the 'episode of care' rather than the patient visit.

The 'episode of care' is gaining traction as an alternative payment model designed to stem Medicare spending increases due greater 'per person' use of the system, not just more users.

What is the episode of care?

For instance, a patient goes into the hospital to get her knee replaced, she stays two days, sees three doctors and gets discharged with home health PT for two weeks - then she gets sent to outpatient PT for one month. All costs, including the pre-hospitalization exam and imaging studies would be 'bundled' into one flat rate.

The current payment model is mainly fee for service during a patient visit - you do the work, you bill for it and you get paid. Fee for service risk is borne almost entirely by Medicare - the private practice or hospital provider only has the risk that not enough patients will show up to cover rent, utilities, salary, etc.

The current administration's budget proposal recommends the 'episode of care' that pays acute care hospitals a single payment for all services connected with a single episode of care, such as a total knee replacement.

This new version of the episode of care as the acute care hospital as 'the banker' - doling out payments to providers down the chain: doctors, surgeons, home health agencies and independent physical therapists.

Surgeons are currently paid using the episode of care model for surgeries.

Physical therapy is considered 'ancillary service' (I hate that term) which is not currently bundled with the surgeon's service.
 
Some of the details are described in the President's budget proposal, this APTA response letter to Senator Max Baucus (D-MT) and in other sources.

Where does risk come from?

Hospital risk is mainly from re-admissions within 30 days of discharge.

Private practice physical therapy risk comes from visit outliers that use more therapy visits than expected.

How can physical therapists manage "Episode Risk"?

Outpatient facilities are judged on functional outcomes - rated by the therapist or self-reported by the patient.

What can you do to improve your patients' functional outcomes?

• Ask your patients about medication compliance (especially use of prescription inhalers for COPD patients).


• Screen each patient for medical pathology (eg: DVT, depression, elevated fear-avoidance beliefs).


• Provide standardized functional outcomes.
  


• Treat pain early - don't use the emergency room for medication refills.

Am I ready for risk?

Other than providing high-quality, patient-centered care I don't feel qualified to evaluate the risks in contracting with acute care hospitals, accepting a fixed payment and bearing the cost if the patient takes 20 visits to get better instead of 10 visits.

Are you ready?

Chiropractors need help in writing treatment notes

A new report from the Office of the Inspector General (OIG) on chiropractic services furnished to Medicare patients shows that chiropractors have as much trouble, or more, than physicians or physical therapists in writing notes on their patient care that show: 

• medical necessity (need)
  
• progress 
  
• skill (decisions) 
  

"Medicare inappropriately paid $178 million for chiropractic claims in 2006 (from a total of $466 million in Medicare chiropractic claims) ...

• 88% of the reviewed claims had inappropriate payments for 'maintenance therapy'
• 26% for undocumented care
  
• 6% for miscoded care
  
• 20% of the claims had multiple errors
  
• 83 % of chiropractic claims failed to meet one or more of the documentation requirements."
  

The Comprehensive Error Rate Testing program Paid Claims Error Rate for chiropractors, PM&R physicians and physical therapists in private practice (PTPP) shows the following error rates for the last three years:

CERT Program Provider Error Rates	2006	2007	2008
PM&R Physicians	9.1%	7.6%	8.9%
Physical Therapists in Private Practice	11.3%	6.1%	7.0%
Chiropractors	16%	11%	10.5%

The provider type with the lowest Paid Claims Error Rate is in bold.

The Executive Director of the Wisconsin Chiropractic Association, Russ Leonard, has called the OIG Report 'discriminatory' because the Medicare definition of 'maintenance therapy' seems to prevent chiropractors from performing chiropractic adjustments "...to maintain or prevent deterioration of a chronic condition."

Since physical therapists are held to the same standard for maintenance therapy the chiropractors claim of discrimination seems unfounded.

The OIG has been no less kind to physicians performing physical therapy - in 2002, the OIG found that 91 percent of PT billed by physicians and allowed by Medicare did not meet Medicare guidelines which resulted in $136 million in improper payments.

Physical therapists aren't off the hook either - reports of individual physical therapists receiving inappropriate payments from Medicare in Texas and Florida have surfaced recently.

What can provider do to show need skill and progress?

When writing your notes, try to answer these questions:

1. Why are you treating this patient?
   
2. How much do you expect them to improve?
   
3. How long will it take?
   
4. How much will it cost?
   
5. What factors (eg: co-morbidities, compliance, family or social issues) may delay or prevent you from meeting these goals?
   

An excellent tool that can help you answer questions #1,#2 and #3 is a baseline self-report questionnaire.

For example, the Neck Disability Index (NDI), developed by a chiropractor, is a simple, cost-effective tool to show medical necessity and, applied over time,  progress.

A complete literature review on the NDI is available in the May 2009 Journal of the Orthopedic and Sports Physical Therapy Association.

Chiropractors treating Medicare patients may need to learn new techniques and gain new tools for developing a Medicare plan of care for rehabilitation.

One of the specific requirements from the OIG report is the development of a chiropractic treatment plan for each patient that...

• includes a recommended level of care
  
• specific treatment goals
  
• and objective measures to evaluate treatment effectiveness
  

The tools needed to measure treatment effectiveness exist, on the sidebar of this blog, and elsewhere.

For a free e-mail tutorial on writing Bulletproof treatment notes using free, public domain tools, like the NDI, sign up below.

What about Bob?

Heavy metals leech from chemicals used in ‘old style’ print-making processes through the skin and hands of workers and into their blood. The printing process exposed workers not only through their skin but also through the air they breathed – chemicals became aerated through heating and splashing.

Bob Smith retired from printing after thirty years of exposing himself to dozens of potentially toxic heavy metals that could have leeched into his blood and caused his rare nerve disease that weakened his muscles, deadened the sensation in his feet and caused him to stumble and fall.

Bob had a disease called peripheral neuropathy that caused the tips of the nerves in his legs to slowly begin dying. Normally, peripheral neuropathy works its way up the nerves destroying sensation and muscle control – first in the toes and feet and working its way up to the thighs. The nerves normally die in a steady, progressive pattern and should have taken years to fully rob Bob of the function of his legs.

Bob could have expected to learn to adapt slowly to the irreversible loss of muscle strength and tone in his legs following nerve death.

Except Bob didn’t have time.

Bob woke one balmy Florida morning in September 2008 to find the nerves of the left foot and leg dead.

Bob’s doctor gave him the devastating news with some puzzlement since Bob had no symptoms in the right leg. Normally, peripheral neuropathy is evenly distributed across both legs at the same time.

Even more puzzling, three weeks later Bob began to regain some function in the left leg. He could feel his toes again. He could put weight on the left foot and stand on the left leg somewhat. Bob and his wife Joann were ecstatic but the doctors were concerned – peripheral neuropathy doesn’t normally get better.

Perhaps the medical diagnosis was wrong?

By Thanksgiving, Bob was walking with only a lightweight plastic brace on his left foot and planning his holiday travel schedule up North with his family. He finished physical therapy and said goodbye to his therapists. Bob was out of therapy only a couple of weeks when devastation struck again – this time the right leg suddenly gave way and Bob reported numbness and weakness all the way to his right hip.

Bob’s specialist medical doctor was stumped and referred Bob to the Mayo clinic in Jacksonville for a complete work up. Bob’s hope for a new diagnosis was ironically fufilled when the Mayo clinic doctors told him he had TWO types of neuropathy, not just one.

Bob also had neurogenic claudication from lumbar spinal stenosis – in addition to his heavy metal poisoning.

Bob struggled through Christmas and New Year’s and it wasn’t until the beginning of February that his therapists started measuring some return of function in his wasted right leg.

He stopped using the walker and began using a cane. Bob is now making steady progress and his therapists expect more from him. His wife, Joann, is at every therapy session and pushes him as hard as the physical therapists push him. Bob has never willingly missed a therapy session in eight months.

The Moral Imperative

Bob meets all of the basic requirements for physical therapy services:

• Need
• Progress and Expected Improvement
• Skilled Decisions

If anyone should get more physical therapy then Bob should.

But, Bob is also an outlier – his eight months of therapy clearly put him beyond the mean and the median number of visits for a typical outpatient therapy patient in the United States.

The Financial Imperative

Medicare spends about $3.6 billion (2006) on outpatient physical therapy and over $400 billion (2008) for all health care payments in the United States.

Prior to 2006, when annual per beneficiary financial limitations (the ‘therapy caps’) began Medicare costs for outpatient physical therapy were rising at over 35% per year.

These "piles of cash" are vulnerable to exploitation by entrepreneurial physicians, physical therapists and other, business-minded, operators.

Medicare and Medicaid comprise 50 percent of all US government improper payments in fiscal year 2008 (~$36 billion dollars).

The Pinch Point

Physical therapists are in the pinch point because we see cases like Bob’s daily – people who deserve more care but are arbitrarily limited by financial constraints imposed by a beleaguered health care marketplace.

Physical therapists are the decision makers for people like Bob – does Bob get more therapy and get better or does he get to just go home and stagnate? I know one clinic whose policy is to discharge the patient at $1,840, arbitrarily.

Bye bye. Go home.

One Man’s Answer

Here is the solution I propose: the physical therapy Justification Statement for exceeding the Therapy Cap. The following is a proposed template that is also available at BulletproofPT.com in downloadable PDF format.

Justification Statement

Since 1/05/09 Mr. Bob Smith has had 40 visits to physical therapy working on right leg 'peripheral neuropathy' and difficulty walking.

In February, Mr. Smith exceeded his annual, per beneficiary financial limitation ("therapy cap") and we recommend using a "-KX" modifier to demonstrate need and expected improvement.

He has shown measurable progress on the following standardized tools:

Self-report measures

1. Lower Extremity Functional Scale (see chart)
2. Oswestry Disablement Scale
3. OPTIMAL Scale

Performance measures

1. Functional Reach Test (see chart)
2. Berg Balance Scale
3. Timed Up and Go Test
4. Single Leg Support Test
5. Rhomberg Test

Impairment measures

1. Supine SLR (see chart)
2. Quadriceps MMT (sitting)
3. Knee Extension AROM (supine)

Additional evidence demonstrating progress and expected future improvement includes the following:

1. Bob decreased his assistive device from a walker to a 4-point quad cane over community distances.

2. His written statement, signed by Bob Smith and his wife, affirms his progressive independence in dressing, grooming and bathing at home. They both desire for Mr. Smith to continue working in physical therapy in order to attain full independence.

3. In 2008, Mr. Smith's left leg recovered from sudden onset 'peripheral neuropathy'. He had a short course of physical therapy and uses the left leg now for walking.


If you are like me and you occasionally get patients like Bob then you need a justification statement. Here is the Medicare reference (p.24) speaking to the need for a separate statement, apart from your PT notes. Use mine. Make your own.

Either way, don't send people like Bob home without their physical therapy.

Bob needs more time.

The Sound and Fury of the Rothstein Debate at PT 2009

“Should the Physical Therapy Profession Endorse Medicare Rules and Regulations as the Standard With All Payers?”

...the setting is genteel, their credentials impeccable but, rest-assured, this smack-down between Larry Benz, DPT and Steve Levine, DPT promises some fireworks but not much else.

The sub-text of this question reads as follows:

"Should Medicare allow less-skilled providers (eg: massage therapists and athletic trainers) to treat patients "classified" with conditions appropriate to their skill level?"(Dr. Benz' apparent position)

Or, should Medicare continue its current regulation requiring that PTs or PTAs provide all treatment to Medicare beneficiaries? (Dr. Levine's apparent position)

Medicare listens to professional societies for consensus positions on standards of practice - especially for specialties where standards of practice are not generally well-known.

But a consensus position from the American Physical Therapy Association allowing, for example, massage therapists to perform massage on Medicare patients fitting a manipulation classification is an open door for physicians to exploit the salary differential and staff their POPTS clinics with massage therapists and other, lesser skilled, physical therapy extenders.

Medicare spends about $3.6 billion (2006) on outpatient physical therapy and over $400 billion (2008) for all health care payments in the United States.

These "piles of cash" are vulnerable to exploitation by entrepreneurial physicians and other, business-minded operators.

Medicare and Medicaid comprise 50 percent of all US government improper payments in fiscal year 2008 (~$36 billion dollars).

Medicare and PT Professionalism

Will Medicare accept an APTA consensus statement in the name of "professionalism, clinical practice and business interests" that promises to cost the United States more money?

Answer

No.

What's the real issue?

The issue should not be about the role of the PT extender - the issue should be about the role of the PT.

What is the future role of the physical therapist in the health care landscape of the United States going forward?

The 2009 Rothstein debate appears to be a sideshow to the real issue:

"Life's but a walking shadow,
a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing."
Macbeth 5:5

Medicare recognizes that PT documentation errors are not fraud

In a somewhat refreshing tone the Government Accounting Office issued a report that showed the US government made $18.6 billion in erroneous payments to Medicaid providers in 2008 but admitted that most of these payments are due to 'procedural glitches' and not fraud.

Deborah Taylor, acting director and chief financial officer of the Centers for Medicare & Medicaid Services at HHS told a panel of the Senate Homeland Security and Governmental Affairs Committee on April 22...

"Most of the improper payments... are generally not due to willful fraud... Rather, most of these errors are the result of documentation and processing mistakes.

Some physical therapists may not understand the money flow involved when Medicare pays a claim for PT services, in any setting...

"The law requires Medicare to pay claims within 14 days of receiving them,"

...explained Peter Ashkenaz, deputy director of media affairs for the Centers for Medicare and Medicaid Services to CNSnews.com.

"Given so little time to verify the services of the doctor or hospital performed before paying for them, Medicare often makes the payments first.

After the fact, they look for possible problems."

90% of the improper payments are due to 'inadequate documentation'. Of the $72 billion in estimated improper payments in 2008, Medicare and Medicaid Services accounted for 50% of the total.

Get the full report here (pdf).

What can physical therapists do to help?

Recognize that Medicare and the federal government are in a pinch: they need to provide mandated benefits and needed services to American citizens and others who qualify but they don't want to get ripped off.

Physical therapists and physicians are in the audit cross hairs not because PTs and MDs are fraudulent or dishonest but because costs are climbing uncontrollably.

How can you protect yourself?

Some of the tips I use in my own Medicare compliance plan (may be different for you) include the following:

• Get a baseline measurement


1. Self-report measures such as the OPTIMAL scale (self-report measures may be more reliable than performance measures and other, so-called, 'objective' tests.)


2. Performance measures - such as the Functional Reach Test to gain predictive information on falls.


3. Impairment measures - 'old school' measures like Straight Leg Raise and ankle dorsiflexion ROM, that still have predictive value.


4. Classification measures - powerful, predictive tools that summarize and assign patients to special treatment groups.


• Use a disablement model - physical therapists should avoid treatment decisions based on pathology. Instead, base your decisions on the ICF model to help you help your patients more.


• Use a compliance template - the Office of the Inspector General (OIG) has shown small practices how to incrementally implement a compliance template with breaking your bank.

There are more points to mention - many of which I discuss in my Bulletproof PT Tutorial you can get for free by signing up below with your first name and e-mail.