'Skilled' Physical Therapy still not settled

'Skilled' physical therapy has been buzzing about lately - if you were lucky enough to catch the Rothstein Debates at PT 2009 in Baltimore then you may already be aware of what I'm about to tell you.

A new report from Developing Outpatient Therapy Alternative (DOTPA) describes, in excruciating detail, the distribution of $4.3 billion dollars paid for Medicare outpatient therapy in 2007.

The report also shows who billed what, for who and where. Without getting into the gory details (I don't want to spoil the ending for you) there are some data here that may give us some insight into physical therapist 'skill'.

This first table shows claim lines while the second table shows payments. Note the columns to the right, labeled 'PTPP' and 'Physician' (POPTs).

click the image to enlarge

This second table shows very much the same pattern in payments.

click the image to enlarge

I'll break it down a little more by carving out the rows for 'Ultrasound', 'Electrical Stimulation' and 'Massage Therapy'.

	PTPP	Physician
Claim Lines
Ultrasound	7.6%	10.6%
Electric Stim	2.8%	9.4%
Massage	1.0%	4.7%
Payments
Ultrasound	2.4%	4.2%
Electric Stim	1.2%	6.5%
Massage	0.7%	4.2%

I wonder what it is about the Medicare patient that demands twice as much ultrasound therapy when seen by a physical therapist employed by a physician?

Do patient findings drive 4-6 times as much electrical stimulation in a POPTs clinic as in my clinic?

Why are physical therapists even billing for massage? Oops! Maybe it's not physical therapists...

With all due respect to my peers who work in physician's offices - the numbers don't lie.

I don't know if the difference comes down to skill, dollars or undefinable but the implications seem clear.

Greater passive modality usage and fewer 'hands on' procedures leaves less room for physical therapists to practice their skills.

Get the full report from Developing Outpatient Therapy Alternatives (DOTPA) and Research Triangle International (RTI) here (Utilization Report 2009).

Betting on Physical Therapy Evaluations

I would bet that soon, physical therapy evaluations could be standardized for all outpatient settings.

For those physical therapists working in

• Inpatient Rehabilitation Facilities
• Skilled Nursing Facilities
• Home Health Agencies

...you may already have taste of standardized evaluations.

Depending on how much credibility you give public/private partnerships like the project called Developing Outpatient Therapy Payment Alternatives (DOTPA) you might wager on the success of their new tool.

DOTPA has created the same tool for all outpatients whether they receive physical, occupational or speech therapy.

Time to complete the tool is expected to be 15-30 minutes per patient.

The new tool will be modeled on the Activity Measure for Post Acute Care - Adaptive Short Form (AM-PAC-ASF) - lovely name, don't you think?

The tool will have separate admission and discharge forms.

The intent of the new tool will be to replace the arbitrary $1,840 therapy cap with a process that aligns payment with patient need.

Now, that's a bet I'll take.

Get details of the new DOTPA tool at www.optherapy.rti.org.

Physical Therapists' Predictions Create Value for Patients and Society

Make predictions using walking speed as a diagnostic and prognostic predictive tool.

Show medical necessity for Medicare physical therapy patients using walking speed as part of your clinic's compliance plan.

When over 40% of all Medicare claim denials are based on Medically (un)Necessary physical therapy and when SO many people need physical therapy it seems apparent that we need quick, simple tools like walking speed to assess who needs (and who doesn't need) physical therapy.

Stacy Fritz, PT, PhD and Michelle Lusardi, PT, PhD recently published Walking Speed: the Sixth Vital Sign in the Journal of Geriatric Physical Therapy.

It seems that Drs. Fritz and Lusardi's tool couldn't have come at a better time.

The current administration is trying to create 'value' in the health care marketplace. Value is typically described as...

Value = Quality / Cost

The trouble is that different groups define 'quality' differently.

• I define quality as the best possible functional outcome for my patient.
  
  
• A surgeon might define quality as an x-ray showing bony fusion.
  
  
• An insurance company might define quality as fewer PT visits or fewer MRI scans per episode of care.
  
  
• The federal government might define quality as a 'public option' that covers 100% of Americans with a basic basket of health care services.

The stated goal of CMS and private/public actors like DOTPA is

"...to develop payment method alternatives to the current financial cap on outpatient therapy services."

Yet these partnerships promise to deliver fruit in no less than five years! You and I can't wait that long - your patients can't wait that long.

Dog Days

As the summer winds down and the second half of 2009 rolls around you will start to see more and more patients who have hit their annual, per beneficiary financial limit (the therapy cap).

How will you justify your services?

In my town, the largest provider of outpatient physical therapy services has a blanket policy...

When the patient hits the $1,840 Medicare cap for PT services they are discharged - no audit risk here!

Unfortunately, our health care market incentivizes physical therapists to deny needed services to eligible patients based on audit risk to the physical therapist.

I Love my Country but I Fear My Government!

Physical therapists need predictive tools that we can hang our hats on when recommending continued therapy for patients over the cap.

Walking speed is also helpful at the evaluation since the physician cannot determine medical necessity for the initial plan of care - that's the job of the PT.

That comes as a surprise to many physical therapists - making accountable decisions is a responsibility many of us are not ready for.

Well, get ready. Walking speed is a new tool that will help you show need and progress if your patient exceeds the $1,840 cap.

Physical therapists shouldn't feel bad

Chiropractors are no better at determining medical necessity and showing functional progress.

47% of chiropractic claims were paid by Medicare in error. Chiropractors should use Fritz' walking speed bar graph to show need and progress for their Medicare patients.

Walking speed measurements are quick, inexpensive and effective. We have no reason not to use them.

Special thanks to Selena Horner, PT blogging at MyPhysicalTherapySpace.com .

What is "Value" in Physical Therapy?

Her physician didn't want her to go.

Diane went to physical therapy under duress.

She didn't want to go.

Her insurance company made her go.

Her insurance company wouldn't pay for a Magnetic Resonance Image (MRI) for neck and back pain unless the patient had one month of physical therapy.

Can MBA's working for insurance companies practice medicine better than Medical Doctors and can MBA's practice rehabilitation better than Physical Therapists?

I don't know - they didn't call me to check before they hired the MBA's.

Anyway, Diane came to my clinic and went through the eval process.

I examined her head and neck posture, her trunk posture, her shoulder motion, her neck motion, her shoulder, neck and trunk strength.

I examined her nerve function...

What the..?

Diane had normal nerve root signs (strength and sensation) but evidence of spastic and pathologic reflexes.

Test Name	Result	Positve Likelihood Ratio
Hoffman's Test	positive	0.97 - 2.23
Knee reflex	hyper-reflexic (3+)
Ankle reflex	hyper-reflexic (3+)
Babinski's sign	downgoing	7.75 - 8.0
Spurling Sign	negative
Diplopia	present
Tinnitis	present

[+LR from Cook et al]

"What are you doing down there?"

Why, you ask, would a physical therapist bother checking a knee reflex in a patient with neck pain?

Well, I say, it's my job - that's what I do.

So what's the big deal?

The point is that I called the doctor (the doctor's nurse actually) and told her the patient wasn't fit for PT.

The doctor's nurse was happy:

"We never thought the patient was fit for PT. We wanted an MRI the first time she saw the doctor. You've just given us ammunition we can use against the insurance company to get an MRI!

Thank you!"

I said you're welcome.

The patient was happy - she 'felt' that something was wrong, that physical therapy was inappropriate at this time.

The insurance company - were they happy? If they truly have the best interests of their benficiaries in mind then they should be happy - they are now paying for Diane's MRI because she has serious neck pathology - not just sore, weak muscles.

Cook et al state the following:

"Magnetic resonance imaging is considered the best imaging method because
it expresses the amount of compression placed on the spinal cord and demonstrates relatively high levels of sensitivity (79%–95%) and specificity (82%–88%) (positive likelihood ratio
(4.39–7.92) negative likelihood ratio (
0.06–0.27) in identifying selected abnormalities such as space-occupying tumors, disk herniation and ligamentous ossification."

The Source of Value

Value is a hot topic in health care today. Policy wonks around America want to find the source of value that will save health care:

Value = Quality / Cost

Did I create value?

I created value for Diane and for the doctor - I'm not sure that I created value for the insurance company because they have a different interpretation of quality.

The Question of Quality

Quality for Diane, the doctor and for me means the best outcome for the patient.

Quality for the insurance company means fewer PT visits, fewer episodes of care and fewer MRI's.

Quality also means determining which of your physical therapy patients DOES NOT need physical therapy.

Diane did not show Medical Necessity for Physical Therapy

When 40% of all Medicare denials are based on inadequate medical necessity it seems almost inappropriate to speak about those patients who DON'T need PT - when so many do.

What skill set is necessary to prove to Medicare auditors that what you do is necessary?

What do you need to write to show that your patient needs you?

This reference from the Medicare Benefit Policy Manual Transmittal 88 (page 26) is redundant, poetic, harmonic and true:

"Patients who need therapy generally respond to therapy, so changes in objective and sometimes to subjective measures of improvement also help establish the need for services."

So, get on the stick, take measures, show progress and, above all, prove your value by demonstrating that no one but you, or another physical therapist, could do what you do.

Ten Questions for Physical Therapists

Are we ready to answer our patients questions?

The Agency for Healthcare Research and Quality (AHRQ) says that Questions are the Answer (to asymmetrical information?) and this series of videos provides a humorous and helpful pathway to asking questions of your health care provider.

This one is funny:

This one is ironic:

This one is musical:

A physical therapists' patient might ask the following 10 questions:

1. Why does my body part hurt?
   
   
2. How do you know what's wrong with me?
   
   
3. What's wrong with me?
   
   
4. How long will it take?
   
   
5. How much will it cost?
   
   
6. How much better will I be if I do physical therapy instead of surgery?
   
   
7. Should therapy hurt before it feels better?
   
   
8. Is it normal to get depressed and frustrated during therapy?
   
   
9. Should I expect insurance to pay for all of the therapy I need to get my old life back?
   
   
10. If I don't feel better in the expected time frame - will you refer me to another therapist who may be able to help more?

If physical therapists can routinely answer patient questions (especially cost) we will be in a much better position to determine our future - professionally and financially.

10 questions every patient should ask - from AHRQ

These are the questions from the AHRQ website that every medical patient should ask - obviously rehabilitation patients should ask sufficiently different questions that they deserve their own list.

1. What is the test for?
   
2. How many times have you done this?
3. When will I get the results?
4. Why do I need this surgery?
5. Are there any alternatives to surgery?
6. What are the possible complications?
7. Which hospital is best for my needs?
8. How do you spell the name of that drug?
9. Are there any side effects?
10. Will this medicine interact with medicines that I'm already taking?

Physical Therapists and Bloom's Taxonomy

Teachers have used Bloom’s taxonomy since 1956 to organize their work and identify their activities.

Physical therapists teach or train our patients, based on the results of our examination and evaluation findings.

What, then do we teach our patients?

Do we teach them something we learned in school? Read in a book or a blog? Heard on the street? Do we teach something we learned at a weekend course?

Or, do we teach something new? Something we created or discovered?

Bloom’s taxonomy helps me understand my point. I’ll use Bloom’s to illustrate:

The pyramid shows the hierarchy of the cognitive domain (that is, mental skills) in Bloom’s taxonomy – the affective (feelings and emotions) and psychomotor (manual or physical skills) domain are not represented here although they are equally important to teachers.

Since I prefer to think of physical therapy decision making as the most important contribution that I can make to improve my patients’ lives then the cognitive domain is the one that best illustrates my point.

The Cognitive Domain of Bloom’s Taxonomy

Remembering, the earliest and broadest domain, must be mastered before any of the higher domains can be achieved. Examples of remembering are:

1. memorizing the origin and insertion of a muscle
2. stating the physiology of an electric modality
3. memorizing predictor variables for a treatment based classification
4. recall of Medicare minimal documentation standards for outpatient PT

Understanding is ownership of knowledge remembered. Examples of understanding are:

1. Recognizing a dysfunctional muscle or motor performance test.
2. Discussing the findings of a patient evaluation with the patient, PTA or physician.
3. Training a new clinician in your clinic’s Medicare compliance program.

Applying your understanding is the next step in learning. Examples of applying include:

1. Problem-solving the results of the physical therapy examination with yourself or with peers.
2. Choosing a treatment based on the examination results.
3. Writing the examination findings in a note.
4. Illustrate to a new grad PT the intent behind Medicare’s ‘medical necessity for physical therapy’ requirement for treatment.

Analysis is the next step in learning. Analysis looks at the underlying structure of an argument and examines motives for why an argument is proposed. Examples of analysis include:

1. Why are predictor variables useful for a lumbar spine examination?
2. What types of outcome measures can we use to show progress for specific physical therapy patients?
3. What are the pros and cons of treatment-based classification in physical therapy?
4. Questioning the ethical implications of Medicare’s exceptions process to the outpatient PT caps

Evaluating an argument requires the student to take a stand. Some examples are:

1. Defend the medical model of spinal dysfunction.
2. Defend the biopsychosocial model of spinal dysfunction.
3. Argue that the exceptions process to the PT caps create the perverse incentive for physical therapists to deny needed services to Medicare beneficiaries based on perceived audit risk.

Creating a product in physical, written or conceptual form is the final step in learning. Some examples include:

1. Peer-reviewed research reports, case studies, clinical commentary, letters-to-the-editor and book reviews, blog posts.
2. Bulletproof Physical Therapy Decisions website (soon to be a book).
3. PhysicalTherapyDiagnosis.com blog.

There's an old (and somewhat cynical) saying in physical therapy - there are therapists with twenty years experience and there are therapists with one year of experience - repeated twenty times.

Which one are you?

Patients learn what physical therapists learn about them.

Each day is a new discovery.

Every patient is a teacher.

What will tomorrow teach you?