"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

Monday, August 3, 2009

Some Red Wine with Your Physical Therapy, Sir?

I don't normally use red wine during my physical therapy sessions (I am a physical therapist). But, these examples of physical therapy from Spain may illuminate the American discussion on health care reform. My information for this blogpost comes from interviews during a 13-day trip to Spain this July. logo of mondariz bottled water

You can get a massage at the Mondariz Balneario Hotel and Spa for about €25 (about $35.89 US dollars).

The cash price for "Vinoterapia Corporal" (Wine Therapy for the Body) at Aguas Santas Hotel Balneario (Saint´s Water Hotel and Spa) in Lugo, Spain is €42 (euros) - about $60.53 US dollars.

The cash price for "Fisioterapia Valoracion y Tratamiento" (physical therapy evaluation and treatment) is €47 - about $67.73 US dollars. A "Chocolate Facial" is €25 while a full-body massage is €35.

My wife has started to enjoy trips to places like Aguas Santas since our kids were born - nobody takes kids to places like this.

Both the Mondariz and Aguas Santas are located in Spain which offers 100% universal healthcare to it´s Spanish citizens and it´s immigrant amnesty beneficiaries.

map of spain

Therefore, nearly every legal permenant resident in Spain has a basic level of health services available to them and their families. The Spaniards I spoke to said they were happy with their healthcare - they usually paid zero out-of-pocket:
Suso, a 45-year old artist-turned-student said that all of his friends and family had healthcare. Suso recently returned to school to learn a new career (printmaking) and both he and Mari, his wife, were able to maintain a health safety net.
Who gets Wine and Chocolate?

So, if physical therapy is free to those who need physical therapy then who is paying for wine and chocolate?

I talked to some local people: a police officer, an assembly line auto worker, a clerk in a nursing home and several physical therapists. This report represents the experiences of about a dozen people receiving and giving PT services from both hospital and private practice PT in the northwestern Spanish region.

The Results

Some of the Spaniards perceived some differences in outpatient physical therapy, depending on who paid the tab - here are some of their statements:
  1. 20% of outpatient private practice physical therapy was paid by private insurance (non-Medicare).
  2. 80% of outpatient PT was cash.
  3. Physical therapists often decided to assign home exercises and modalities to Medicare patients.
  4. Physical therapists often decided perform massage, mobilization and manipulation for private pay patients.
  5. Private insurance paid better (I didn´t get access to a private fee schedule, unfortunately).
Medicare audits are a fact of life, just like in the USA, according to Jose, a hospital-based PT.

I asked another physical therapist, Gaspar of Viterapia, if Medicare patients were treated different because Medicare payment were so low. I expected to hear the worst but I was happy to hear Gaspar emphatically deny that patients received any different level of care. Gaspar did not, however, see Medicare patients in his private practice - only at the hospital where he worked occasionally.

Most solo physical therapists in private practice, I got the impression, did not see Medicare patients privately.

Only two PT providers in Vigo, a city of 300,000 on the cold azure, shores of the North Atlantic, saw outpatient Medicare using the volume-model of PT production to make economic sense by seeing 20 or more patients per PT per day. These clinics saw the Medicare in exchange for 125-600 referrals per month, it was rumored. Gaspar, in contrast, was able to run a nice, 2-PT clinic with one office girl to answer phones and book appointments. He saw 12 patient per day. His rates varied from €25 to €55 per visit.

Also, Gaspar told me he takes no notes, no chart, no documentation - patient clinical records are kept of a 3x5 index card with name, physician's diagnosis, and a little else.

Gaspar takes 80% cash pay in his office. Gaspar's private clinic opened at 8:30-1pm, then they took a siesta (really!) and re-opened at 6pm-10pm (really!). And,yes, it's OK to enjoy a glass of red wine at lunch, in Spain.

I met Gaspar at 9:30pm in his last appointment slot and afterwards we went to a little cafe for the interview.

Since Gaspar did not take Medicare he said he did not have to worry about audit risk. Gaspar's private pay patients did not need a physicians' referral to get physical therapy. All physical therapists in Spain are licensed and their license is signed by the King of Spain - that means no variations in practice act regulations depending on your address.

Medical necessity for physical therapy is still performed by physicians since physicians perform all of the evaluation, testing and measurements.

Jose (the hospital PT) didn´t use any self-report, performance-level or classification measurements in the treatment plan. He did cite Florence P. Kendall´s Muscles: Testing and Function With Posture and Pain (the book, first published in 1949, has been published in eight languages). Jose said he did perform Manual Muscle Testing on his patients.

Gaspar performed mainly massage and mobilization - he had just finished a Freddy Kaltenborn course in Zaragoza. The Spanish PT association paid for part of Gaspar's course.

Gaspar was familiar with some performance tests, such as Single Leg Support, Sharpened Rhomberg, Timed Up and Go but he stated that these tests were considered neurological tests and he didn't use them. He did not used any self-report questionnaires. Gaspar had heard of classification predictor variables but he didn't use them.

In the United States, physicians delegate reponsibility to physical therapists for performing an evaluation and demonstrating medical necessity, based on objective tests and measures (mentioned above).

Lola, another hospital PT, said she had heard that US physical therapists were professionally 'more advanced' than Spanish physical therapists. Lola stated...
"Me encanta el calor y masaje para el tratamiento de mis pacientes"
(I love heat and massage for treating my patients)
Lola did her notes on computer but she said they were very brief narratives and did not use any of the aforementioned self-report, performance-level or classification measures.

Take Home Message

Gaspar lives well, seems to enjoy his work and has operated for the eleven years I have known him as a private practice physical therapist in a country that ensures basic health coverage to 100% of it's people.

Furthermore, physical therapists in Spain have managed to avoid the encumbrance of clinical documentation that American physical therapists put up with. They have adopted computers.

In some respects (decision making), Spanish physical therapists don't seem as far along the journey to clinical autonomy as American physical therapists. Their decision-making is still the in domain of the physician.

In other respects (direct access), Spanish physical therapists live in a more enlightened world.

It seems that wine and chocolate are reserved for those who pay for them and some Spaniards, obviously, want to pay. The exciting aspect of my trip was the finding that some Spaniards will also pay for their physical therapy out-of-pocket. Enough Spaniards pay for PT so that small, private practice physical therapists can survive, even thrive, in a 100% universal health care country.

Now, will Americans pay for PT?

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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 .

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