Physical Therapy, Silver Coins and Green Eyeshades

We need a common coin of the realm.

After Napoleon's final defeat at the Battle of Waterloo on June 18, 1815 the British bond market rallied as investors predicted lower government borrowing for future wars. Nathan Rothschild arrived in London just hours ahead of the news of the battle's outcome and began buying up British war bonds at bargain basement prices.

Bond prices rose as yields fell and Rothschild sold at a huge profit. Rothschild's future was made in those months following Waterloo. Many sources credit Rothschild as the pre-eminent banker, speculator and, some say, the most powerful financier of the nineteenth century.

After securing his fortune Nathan Rothschild went on to become famous and also managed to create a standard that still affects our lives today. He demanded, and got, due to his money and influence, a uniform system for paying bond holders in sterling silver - no matter which country they were from. Investors no longer had to go to London to receive their bond coupon payments and sterling silver became the coin of the European investing realm.

Improvements in payments made bonds more attractive to investors and, ultimately, easier for Rothschild to sell. Bond holders were better off, governments gained access to new funding and Rothschild got richer.

I see a parallel here.

Couldn't physical therapists demand a uniform measurement system for rehabilitation outcomes? If all rehabilitation professionals had a common measurement system (eg: standardized performance, self-report, impairment or classification measures) then physical therapist outcomes could be compared with other rehab professionals. Right now, the only available comparisons are based on setting (eg: POPTS, PTPP, hospitals, etc.) and the only available measure is cost.

What if physical therapists could compete with physicians on outcomes?

Physician owned physical therapy clinics (POPTs) are slightly lower in annual Medicare, per beneficiary costs ($522) than their Physical Therapist in Private Practice (PTPP) peers ($871) but that may be due to the 'Flying Below the Radar' effect.

Unfortunately, cost is not the best measure of competitiveness. Not if you believe that quality service is a better measure. WalMart competes on cost - would you buy healthcare from WalMart?

Physical Therapists under Automated Review

Right now, in America, powerful computer algorithms are sifting your claims data and looking for patterns outside the 'bell curve' - do you do a lot of manual therapy?

Four manual therapy units (1 hour) per visit? You are outside the curve.

Automated reviews, conducted by Recovery Audit Contractors (men in green eyeshades), are looking for duplicate payments like two spinal tractions in one day. Spinal traction is a 'supervised modality' - you set it and go treat another patient. Totally legal - however you can't charge more than one per day per patient.

Recovery Audit Contractors (RACs) made some good money in Florida, California and New York from 2005 to 2008 during the RAC Demonstration Audit with automated reviews.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

I posted this chart originally on June 8, 2009 from my own clinic data as well as US government published data from the RAC Demonstration Audit Report (June 2008)

I define 'good money' as the piddling amount RACs 'recovered' from me because cost/investment = $0 and return = $80. To the men in green eyeshades the calculated ROI is infinite.

Michael Apolski's Medicare Update blog is quoted in the September 2009 issue of Orthopaedic Practice Management - he discusses automated reviews on page 99.

"RACs can analyze claims using two methods. During “automated” review, they attempt to find “the low-hanging fruit” by making a claim determination at the system level without even reviewing the medical record, Apolskis says."

Alternative Physical Therapy Payments

The current lead contender for a 'common coin of the realm' is a tool being developed by a private-public partnership, Research Triangle Institute (RTI).

I have a couple of concerns with RTI's Developing Outpatient Therapy Payment Alternatives (DOTPA) project:

1. Despite their attempts at outreach they still have a government mandate - they can ram it down our throats, if they want to.
   
   
2. Their assessment tool is expected to take 15-30 minutes per patient! No time left for patient-therapist collaboration or establishing rapport.
   
   
3. Is RTI re-inventing the wheel? Physical therapists already know how to assess our patients - do we need a new setting-specific tool? Couldn't we do better with a set of condition-specific measures for common, high-volume conditions like the Oswesty for lower back pain or the SPADI for shoulder pain? Let the clinician choose.
   
   
4. How many physicians could manage the transition from profit-driven POPTs to outcomes-driven care? Would running a PT clinic under those circumstances (ie: when you're not a PT) be worth the 'hassle"?

Nathan Rothschild seized a singular moment in world history and used it to shape the future of finance - could physical therapists seize healthcare reform as a springboard to position evidence based physical therapy as the universal standard by which all rehabilitation professionals are judged?

Could we 'sell' physical therapy to a skeptical public of payers and government policymakers when we are all better off with outcomes?

An open letter to the American Physical Therapy Association

This letter was sent to a contact at the APTA on September 21, 2009.

This letter is intended to initiate a discussion and propose a course of action that is in the best interests of Medicare physical therapy beneficiaries, the American healthcare system and physical therapists everywhere.

Why do Medicare auditors assess 'skilled therapy' as a criteria of payment? Because they lack an alternative measure of value.

Evidence based physical therapy, such as classification decision rules, have been shown to improve outcomes, decrease expensive testing, medication use and invasive procedures.

Can physical therapists avoid arbitrary, punitive Medicare audit denials by documenting the use of classification predictor variables and decision rules in the plan of care, daily notes and discharge?

Couldn't a commitment from Medicare to "immunize" physical therapists who document evidence based therapy from the 'skilled therapy' criteria of Medicare audits prompt a sea-change in clinician behavior to adopt evidence-based methods more quickly?

Medical doctors and legislators have sought a similar immunization, based on evidence based care, from the current administration as regards defensive medicine.

Why couldn't physical therapists, the only doctoring profession subject to time-based CPT codes, put forth similar argument as regards Medicare audits?

Thank you for your consideration,

Tim Richardson, PT

Can Evidence Based Medicine Save Physical Therapy From 'Skilled Therapy'?

Can powerful new tools used by physical therapists prevent a Medicare audit?

If you write in your note tests that predict the outcome of treatment could that note be exempt from a "partial denial of a therapy claim" that requires oodles of handwritten narrative "trumpeting clinicians' concerns"?


Rather than trumpeting your concern in writing wouldn't you prefer to spend time thinking about how to get your patient better?

What new ways could you think of to provide 'value' to America's struggling healthcare marketplace?

Sources of Value in Physical Therapy
Old	New
Osteokinematics	Manipulation predictor variables
Gait analysis	Gait Velocity measurements
Narrative descriptors of "assistance"	Self-report scales (eg: ABC test)
Falls history for predicting future falls risk	Testing specified populations with known pre-test probabilities of falling down using tests with known likelihood ratios
Pathology model	Biopsychosocial model
Physicians' diagnosis	Physical Therapy Diagnosis

Much as physicians inflate health care costs with defensive medicine so to are physical therapists forced to waste precious time, money and energy with defensive documentation. Most would agree that documentation doesn't add 'value' to healthcare.

Even if you get your patient better in a reasonable time frame using evidence based physical therapy Medicare can come in and retroactively snatch away your payment dollars if you haven't trumpeted your concern in your notes and charts that each and every intervention is 'skilled' - nevermind that no uniform definition of 'skilled therapy' exists.

Defensive Documentation and Defensive Medicine

The American Medical Association as gone on record saying it will support legislation aiming to shave costs on defensive medicine by providing immunity from lawsuits for physicians who practice evidence based medicine. Health and Human Services Department economists estimate America could save $60-108 billion per year with malpractice reform.

The Health Care OverUse Reform Today Act (HealthCOURT Act - H.R. 3372) contains language that provides immunity from lawsuits to physicians who practice evidence-based medicine. It's purpose is to

"...establish an affirmative defense in medical malpractice actions based on compliance with best practices guidelines"

The HealthCOURT Act may not make it out of committee but Democrats seem willing to trade some aspect of malpractice reform for passage of a larger health care reform package.

The Medical Group Management Association (MGMA) sent this letter to Congress in May 2009 outlining their position on the use of evidence based guidelines and malpractice reform:

"Allow use of evidence-based guidelines to provide mitigating protection in professional liability cases.

In some circumstances allow these guideless to offer immunity."

How does Defensive Medicine relate to "Skilled Therapy"?

Why did Medicare chose to use a 'skilled therapy' criteria to evaluate your notes and charts? Because they had no alternative source of value!

Today, in 2009, physical therapists create value by assigning patients to classification treatment groups based on the presence or absence of statistically determined predictor variables. Physical therapy evidence is much better today than it was 15-20 years ago when Medicare auditors first began scrutinizing PT charts and notes, en masse.

One of my blog readers asked me not long ago...

"If a physical therapist is performing the therapy then isn't it, by definition, skilled therapy?"

I wasn't sure whether I should cry or laugh at the innocence, the naiveté displayed by this statement.

Over 40% of PT charges are reported to lack documentation supporting 'skilled therapy' - the result is 'maintenance therapy' unbillable to Medicare or most third party payers.

Skilled therapy has been in the Medicare Manuals since at least 1988, according to my research. The enforcement of skilled therapy, however, by the self-appointed police of documentation, those ghosts of past PT professors professing to know, from your notes, the level of your intent, skill, intelligence, care and effort that went into getting your patient better has only emerged since the early part of the 21st century.

Skilled therapy emerged from skilled nursing facilities where many people went following an acute hospitalization. Medicare began in 1965 as a program for treating acute, short-term medical problems for which a cure could be expected. For those persons, with 2-5 chronic conditions like...

• congestive heart failure
• obstructive pulmonary disease
• diabetes
• hypertension
• mental disorders

...the costs are many times higher than average and the expected improvement is less than average.

Often, there is no 'cure' for these conditions so Medicare mandated 'skilled therapy' as a way to ensure that certified professionals provided services and that patient safety was maintained.

Skilled Therapy and 'Progress'

Progress, the "improvement standard" so often unattainable in skilled nursing, is required in outpatient physical therapy. Getting and keeping people living independently keeps them in the lowest cost healthcare setting in America, their homes.

Nevertheless, local contractors have been criticized for applying an "improvement standard" as a way to deny needed care and save money...

"...for certain services, such as outpatient therapy services, Medicare's policies impose improvement standards that are inconsistent with the statute.

The Medicare statute does not demand a showing of improvement to find services medically necessary or to cover treatment of an illness or an injury.

The statutory criterion for treatment of an illness or injury applies regardless of where the covered service is provided, be it in a skilled nursing facility, at home, or as an outpatient."

An improvement standard in outpatient therapy clinics is less problematic today than it was when those words were written (2003). Today, about 48% of physical therapists use outcome measures - most of those are probably self-report measures like the...

• OPTIMAL scale
• Oswestry scale
• Fear-Avoidance Beliefs scale
• Lower Extremity Functional scale
• Shoulder Pain and Disability scale

Self report measures are the the main component in computerized patient assessments designed to replace Medicare fee-for-service within the next five years. One of their benefits is their ability to show need (medical necessity) and progress (improvement).

But, skilled therapy remains problematic.

Today, the search for 'skilled therapy' in PT notes and charts is an arbitrary scavenger hunt - paying off for auditors in daily notes when the PT is tired, busy, brief or vague.

Why not use specific evidence-based criteria: numbers, valid tests & measures, standardized outcomes and daily measurements centered on patient function?

I recommend physical therapists trade our allegiance to our 'old' practice patterns, based on observation and experience, for 'new' evidence based predictive models in exchange for immunity from the scourge of skilled therapy denials in Medicare audits.

The 10 Most Important Words in Evidence Based Physical Therapy

Bias – the systematic deviation from the truth.

Atun Gawande, MD said it this way:

"Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes.

The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly.

It is unduly swayed by desire and emotion and even the time of day. It is affected by the order in which information is presented and how problems are framed."

Diagnosis is to “discern” or “distinguish” the nature of the patients’ problem. The original Greek word meant “to learn”.

In physical therapy, diagnosis is the process of integrating data obtained from the patient examination in order to treat and inform the plan of care, perform interventions and to make a prognosis (prediction).

Gold Standard – a test that is assumed to be valid can be compared to the measure of interest. In TBC, outcomes are the measure of interest. The manipulation and stabilization derivation studies used a 50% improvement in the Oswestry Disablement Score as the gold standard.

Many medical gold standards are imaging findings because medical tests are trying to confirm a pathoanatomic diagnosis.

Pretest Probability – the prevalence of a disease in the population (of your patients) at a given point in time. Steven McGee, in Evidence Based Physical Diagnosis states:

“Pretest probability is the starting point for all clinical decisions.”

Positive Likelihood Ratio “describes how probability changes when a test finding is present.

Findings whose LR is greater than one increase the probability of disease; the greater the LR the more compelling the argument for disease.” (Steven McGee)

The relationship between the finding and the diagnosis/outcome is defined numerically by the positive likelihood ratio.

Negative Likelihood Ratio “describes how probability changes when a test finding is absent.

Findings whose LR lie between zero and one decrease the probability of disease; the closer the LR is to zero the more convincing the finding argues against disease” (ibid)

The relationship between the finding and the diagnosis/outcome is defined numerically by the negative likelihood ratio.

Cookbook Medicine - a term used to deride the algorithmic simplicity of evidence based medicine, usually by those who prefer an observational, personal or ambiguous approach to decision making.

Diagnostic Perfection - the 'elusive search for diagnostic perfection' is defined by the test that identifies all patients with the condition of interest and rejects all patients without the condition of interest.

This impossible ideal is numerically defined by a test with a sensitivity and a specificity of 1.0.

A culture of measurement is another ideal that may be possible.

New tools have been described that trump the puny skills I graduated with in 1992 (eg: MMT) - perhaps the physical therapy profession is reaching a critical mass where measurement will become the standard and not the ideal.

Compliance – a legalistic term rather than a clinical term. Compliance cannot be memorized or practiced according to evidence-based standards.

Compliance is an ongoing, evolving process of the following:

1. self-audit
2. standardization
3. accountability
4. training
5. corrective action
6. communication
7. publication of your work

Physical therapy managers struggle trying to balance the paperwork burden of compliance and optimizing the therapists' time treating patients. More paperwork usually make the corporate lawyers happy while more time treating patients makes the therapists and the patients happy.

Ironically, too much paperwork forces corporate PTs and hospital PTs to rely more on unskilled aides, which may increase audit liability when you're caught.

So, how come compliance is an important word in evidence based physical therapy?

Well, consider this...

Recently, the incoming American Medical Association President Dr. J. James Rohack declared...

"Defensive medicine is another cost driver in the health system that will only abate with medical liability reform. For example, adherence to nationally recognized evidence-based guidelines can reduce the ordering of unnecessary tests if physicians no longer have to fear merit-less lawsuits.

President Obama has recognized the need for liability reform, and we urge Congress to include effective liability protections when guidelines are followed."

What if we recognized that 40% of physical therapy Medicare denials are "maintenance therapy" based on an auditor's judgement of a PT note. The note may appear "unskilled" since therapeutic exercise is, by nature, repetitious.

The physical therapy plan of care could appear repetitive even though the patient gets better, goals are met and outcomes improve.

Medicare audits and audit protection activities are a cost driver (part of the estimated 31% administrative costs in health care) that will only abate when Medicare stops auditing the process of how physical therapists deliver care (eg: "skilled" care, 8-minute rule, -KX & -59 modifiers, etc.) and starts looking at the outcome of care.

How much health care value will be unlocked when physical therapists are free to focus on patient outcomes instead of writing down every set, rep, position and variation of treatment we prescribe?

What process do auditors use to evaluate physical therapists charts? Could that process be subject to bias?

American medicine has recognized the need for an outcomes oriented system and we urge Medicare auditors to go easy on physical therapists when evidence based guidelines are followed.

Why TBC is not "Cookbook" medicine

I got it wrong!

This is first correction on Physical Therapy Diagnosis (that I'll admit to) - so don't go telling my wife or my mom!

I posted three days ago that a physical therapist could use a heuristic adjustment (a 'rule-of-thumb') to published estimates of pre-test probabilities for treatment based classification (TBC) groups, for example:

• Stabilization = 33%
• Lumbar Manipulation = 45%
• Thoracic Manipulation for Neck Pain = 54%


The example I used was of my own patient population here on the West Coast of Florida whose demographics I posted here.

My patients were measurably different from published norms for a stabilization group in the TBC derivation study.

I mistakenly recommended an downward adjustment to the pre-test probability based on age. To check my adjustment I e-mailed Dr. Steven McGee, author of Evidence Based Physical Diagnosis, who e-mailed back with the following:

"The only way to adjust published pretest probability is to measure your own clinical experience.

For example, in the last 100 patients you have seen with shoulder pain, how many have had rotator cuff disease?

This is the pretest probability figure to which you would apply Likelihood Ratios of diagnostic tests."

Steve McGee



Dr. McGee's book recommends a simple "bedside" approach to using likelihood ratios in the clinic that can assist physical therapists learning about TBC.

No calculators.

No nomograms.

Just you and the patient and a few simple tests and measures.

Dr. McGee's Mnemonic

Dr. McGee does a great job in his book but I'll try here to describe the clinical mnemonic:

Memorize 2,5 and 10: these are positive likelihood ratios. The approximate associated upward shifts in post-test probability are +15%, +30% and +45%.

Memorize 1/2, 1/5 and 1/10 (notice the pattern?): these are negative likelihood ratios. The approximate associated downward shifts in post-test probability are -15%, -30% and -45%.

Measuring Treatment Responders for 'Functional' Diagnoses

To measure the pre-test probability of an outcome is the same as a diagnosis. Outcomes what we are trying to improve in physical therapy TBC.

First, test every patient with lower back pain using your stabilization predictor tests:

1. Age less than 40
2. SLR > 90 degrees
3. Positive Prone Instability Test
4. Positive Gower's sign

Who is positive on the rule?

For example, The next 100 patients in my clinic who present with lower back pain who meet the stabilization inclusion criteria get tested as described above.

Those with at least 3 positive tests are my treatment responders - let's say 20 patients score at least 3 positive tests.

The pre-test probability is 20/100 = 20%.

At the Bedside

For a patient with 3 or more positive tests the positive likelihood ratio is 4.0. According to Dr. Magee's mnemonic the upward shift is between 15% and 30% (about 25%). Add that to my pre-test probability...

20% + 25% = 45%


Stabilization is no better than some randomly chosen clinical intervention for improving this patient's lower back pain. We should try to find an alternative intervention.

By using our own patients'characteristics along with published estimates of likelihood ratios we can "personalize" TBC. As Dr. McGee says in his book...

"...because the best estimate of pretest probability incorporates information from the clinician's own practice - how specific underlying diseases, risks and exposures make diseases more or less likely - the practice of evidence-based medicine is never "cookbook"."

Dr. McGee's paper on "Simplifying Likelihood Ratios" is a great way to get started using this valuable tool.

An excellent tutorial on physical therapy diagnosis and the use of pre-test probability is available from the University of Pittsburg and Dr. Julie Fritz.