"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, May 19, 2009

Physical Therapists: Ready for some Risk?

Manatee Memorial Hospital Bradenton, Florida
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?

Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.