Outpatient physical therapy and 17-page Medicare Evaluations

Outpatient physical therapists get ready - you may soon have to perform 17-page Medicare initial evaluations like your brothers and sisters in home health care.

The project Developing Outpatient Therapy Payment Alternatives (DOTPA) has issued these evaluation forms as 'prototypes' - presumably for provider input.

The proposed evaluation forms are available from the Research Triangle International (RTI) website - get the eval and discharge for institutional settings (eg: nursing facilities) (25 pages) and for community based settings (eg: PTPP).

The outpatient PT discharge note is only 16 pages. Yippee!

The point of this new 'provider burden' is to change the Medicare payment system to a 'value based' system where physical therapists are paid based on the 'risk adjusted' complexity of the patients we see.

For example, if you see a 75-year old patient with the following:

• lower back pain
• high fear avoidance beliefs
• depression
• lives alone
• smokes and drinks alcohol
• appears to have limited understanding/awareness of their health condition and its possible outcomes

...you may be entitled to higher payments based on these listed risk factors.

I say may because no one knows what this alternative payment system will look like.

Currently, the OASIS (Outcome and Assessment Information Set) outcome data does not appear to show outcomes ranked by risk factor.

The most relevant outcome for outpatient care - number of visits - is obviously not as relevant to home health care so we couldn't expect guidance on number of visits.

Utilization outcomes for OASIS instead look at the following:

• Received Emergency Care
• Discharged (home) from Home Health Care
• Admitted to an Acute Care Hospital

OASIS also shows outcomes ranked by state as the percentage of patients who 'improved' - for example:

...of the home health care patients treated in Florida treated between June 2007 and June 2008:

• 46% improved in their ability to walk
• 27% were re-hospitalized
• 17% went to the emergency room prior to discharge

I have a few questions for RTI before they recommend that Medicare implement a 17-page OASIS-style eval/discharge assessment in outpatient physical therapy.

1. What is 'improved'?
2. How far did they walk?
3. How fast did they walk?
4. Are they satisfied with their home health care?
5. How long did the episode of care last?
6. How much did it cost?

Brothers and sisters, what questions do you have?

Is Health Care Fraud Inflated?

Health care fraud costs Americans between $68 and $220 billion per year, according to a new report from the School of Public Health and Health Services at the George Washington University.

The large gap in the estimation of fraud costs exists, in my opinion, because of the imprecise definition of fraud. Black’s Law Dictionary defines fraud as...

“a knowing misrepresentation of the truth or concealment of a material fact to induce another to act to his or her detriment.”

Improper payment, the report goes on, is different from fraud. Improper payment is loosely defined as...

• errors in documentation
• errors in coding
• errors in reporting
• errors in verification
• ...and other technical matters related to administration

Fraud Exposed

The current administration and a new CBS segment on '60 minutes' claim that $60 billion in healthcare 'fraud' can be eliminated and that these savings can be used to pay for health care reform.

Unfortunately, most 'fraud' is not like that perpetrated by the barely literate 'Tony' in the new CBS video The $60 Billion Fraud (14 minutes) and it may not even be fraud - witness the $992.7 billion recovered under the Recovery Audit Contractors (RAC) Demonstration project from March 2005 to March 2008 in six states (New York, California, Florida initially and Massachusetts, South Carolina, and Arizona added summer 2007)

About 85% of the recovered overpayments came from inpatient hospitals ($828.3 million). Most of these overpayments fit the description of 'incorrect payments' - not fraud.

Inpatient hospital administrators are hardly the type featured by CBS in their inflammatory video. Incorrect payments arise the complexity of billing and coding rather than 'a knowing misrepresentation'.

The RAC Permanent audits are already showing, in their first year (2009), a 3x higher rate of overturned appeals than the standard Medicare audits. This implies that RACs are incorrectly interpreting Medicare regulations and denying too many claims.

Another implication is that the rate of incorrect payments (at least under RACs) is inflated.

Do academics and the media have an agenda?

I wonder if the media (like CBS) inflates the rate of healthcare fraud for its own purposes?

The George Washington report goes on to say that:

"...80% of healthcare fraud is committed by medical providers..."

Yet the same report lists the results of a legal search engine query from 2000-2009 based on the type of company: provider, insurer or pharmaceutical. The fraud was both public (Medicare) and private.

Humana Inc. is categorized with the insurers even though it is described as a 'major hospital corporation-affiliated private insurer'.

Industry	Recovery (millions)	Per Cent
Provider	$2,122.25	38.9%
Insurer	$890	16.3%
Pharmaceutical	$2,459.75	44.9%
data from Rosenbaum et al. Health Insurance Fraud: An Overview. June 2009; George Washington University, School of Public Health

It is worth noting that the Insurer group is made up of 4-5 major American companies (UnitedHealth Group, Humana, AmeriGroup, HealthNet, et al) and the Pharmaceutical group is made of just over 15 major, international companies (TAP, McKesson, Merck, Serono Group, Wyeth, AstraZeneca et al).

The Provider group, however, is made up of over 5,500 American hospitals, large and small, and innumerable private practices, group practices and billing entities with differing levels of compliance sophistication.

These data hardly support the "80% of health care fraud is from providers" assertion.

It also strains credulity to think that the $6 billion or so over the last 9 years could somehow morph into the expected $60 billion annual savings required to pay for health reform.

Three reasons why POPTs will give way to PTPP in 2010

Just this week three things have happened that lead me to question the survivability of the physician-owned physical therapy (POPT) model in 2010.

By the way, none of this seems to be directly affected by the direction of the health care reform debates - whichever way reform goes the POPT outcome seems destined to happen.

ONE

A Medicare Payment Advisory Commission (MedPAC) meeting October 8th listened to APTA testimony on physician ownership of physical therapy clinics. MedPAC addressed concerns about Medicare PT volume growth and ownership of PT.

Physicians who own services, like PT, to which they refer have a conflict of interests (their interests vs. their patients' best interests).

MedPAC outlined these concerns in a PowerPoint presentation by staffer Ariel Winter whose concerns are the following:

1. Could lead to higher overall volume through greater capacity and financial incentives.
   
   
2. Several studies find that physician self-referral is associated with higher volume.
   
   
3. Unclear whether additional services are appropriate or contribute to improved outcomes.

TWO

Jim Needham, former CEO of a Florida POPT, predicts a sell-off due to difficulty with compliance and transparency requirements especially small physician practices that employ physical therapists.

Jim does suggest that costs (the subject of the current debate) are the primary driver of new physician compliance legislation.

You can sign up to hear Jim's presentation in Palmetto, Florida on November 7th or November 21st at BulletproofPT.com.

THREE

My phone has been ringing off the hook from business brokers and 'principals' (guys and gals with money) who all of a sudden want to invest in outpatient physical therapy practices.

My phone rings because I sold two clinics in two separate transactions in the last two years so I'm on a list somewhere. Lucky me.

Do they know something we don't?

Maybe it's just a thaw in the frozen credit markets but physical therapy business sales are getting hot once more.

The other consideration is that investors perceive increased future expected cash flows to Physical Therapists in Private Practice (PTPP) and they see PTPPs selling for all-time historically low valuations and they want a bargain.

Maybe 2010 will be the year of the PTPP.

My advice to PTPP owners - hang tight, this may be your year.

Heads Up! Physical Therapists in Private Practice (PTPP)

The annual issuance of the Office of the Inspector General's (OIG) 2010 Work Plan sets the tempo for all subsequent Medicare audits - since the OIG is the agency that actually audits Medicare (CMS).

Here is what the Work Plan actually says about physical therapists in private practice:

"Outpatient Physical Therapy Services Provided by Independent Therapists

We will review outpatient physical therapy services provided by independent therapists to determine whether they are in compliance with Medicare reimbursement regulations.

The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.”

CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services.

Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented.

Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements.

(OAS; W-00-10-35220; various reviews; expected issue date: FY 2010; new start)"
(page 29)

Physical therapists in Private practice should focus their attention on two areas to make sure that their compliance plan meets Medicare requirements:

Process Measures such as the following:

• 8-minute rule
  
  
• -kx modifiers and the arbitrary PT caps
  
  
• PT/PTA supervision requirements
  
  
• Medicare Minimal Documentation requirements
  
  
• ‘Skilled physical therapy’
  
  
• One-on-one procedure codes
  
  
• Untimed modality codes
  
  
• -59 modifiers and CPT code edits
  
  
• Physician certification of the physical therapy plan of care

Evidence-based physical therapists who truly care about their patients and about the job we do will also want to direct their attention to Outcome Measures such as the following:

• Patient self-report outcomes and questionnaires (eg: OPTIMAL, LEFS, etc.)
  
  
• Therapist-administered performance tests (eg: Gait Velocity, TUG Test, etc.)
  
  
• Impairment-level tests and measures (eg: SLR, neck rotation, etc.)

Finally, one self-administered process measure is Treatment Based Classification (TBC), which has the potential to...

• save costs,
  
  
• improve outcomes and
  
  
• elevate physical therapist decision making

TBC can show Medical Necessity and Skilled Therapy - two important areas of Medicare Minimal Documentation requirements.

To learn more about TBC and Medicare compliance you can attend one of the Classification Seminars in Palmetto, Florida on November 7th or 21st at the Medical Arts Rehabilitation physical therapy clinic from 9am to 4pm.

You can sign-up online at BulletproofPT.com

POPTs Leader Predicts Massive Sell-Off under Health Care Reform

The Senate Finance Committee, on Tuesday October 13th, just voted 14-9 to move the fifth and final version of healthcare reform out of committee and back to the Senate for merger with more generous versions of health reform legislation passed earlier this year.

The latest measure passed with a party line vote (Democrats outnumber Republicans 13-9 on the committee) - with Olympia Snowe (R-Maine) siding with Democrats.

In Bradenton, Florida former Physician Owned Physical Therapy (POPT) clinic leader Jim Needham, CEO (MBA) predicts ominous tidings for his former employers as a result of this legislation.

Some of Jim's key points:

Why there is "Momentum Against Physician Ownership in Ancillaries (Physical Therapy)"

1. "Significant trend data showing increased payment to physicians in relationship to physician ownership growth"


2. "Generally they get reimbursement rates based on their contracts which are greater than independent PTs can get"


3. Jim predicts a 33% chance that POPTs will be ruled illegal within three years

I don't want to spoil Jim's presentation but suffice to say that much of this information is rather volatile - most POPT physicians may not even be aware of the transparency and compliance implications that Healthcare Reform will bring to their practices!

We've "mashed-up" Jim's presentation with an existing seminar on November 7th or November 21st and we're hoping the two topics are complementary:

"Classification Decision Making for Medical Necessity and Skilled Physical Therapy"

with Special Guest former POPTs CEO

Jim Needham

"Competing With POPTs under Health Care Reform"

Jim will go into greater detail during his presentation in Palmetto on November 7t and 21st and you can sign up now at http://www.bulletproofpt.com/.

The online option lets you pay with PayPal.

You can also call 941.729.1800 to register over the phone.

Finally, you can print the webpage at http://www.bulletproofpt.com/ and mail in your application along with your check - don't wait because the Early Bird Discount expires 5-days before each course.

What will health care reform bring for American physical therapists in private practice (PTPP)?

Hard to say.

Some aspects are obviously positive, such as greater transparency in physician self-referral. Other aspects may not be so positive - such as a failure to reform the physician fee schedule and the (un)Sustainable Growth Rate (SGR).

For greater insight and success in 2010 come and see Jim's presentation.

What are your thoughts?

Sign up now for the course!

Don't forget to fill out and send in your application form.

Dates

Prior to November 2 $175.00Prior to November 16 $200.00

How to Sell Physical Therapy

How good are you at 'selling' your therapy?

Can you 'close' the deal?

Or, do you let the customer slip away?

If your customer slips away does another, better 'marketed' professional (MD ortho, DC, Pain doc, etc.) provide the care they need?

Maybe physical therapists should consider how we position ourselves when it comes time to 'close the sale' - according to Israeli researchers using American outcome tools:

"Compliance with self-exercise programs was one of the strongest predictors overall and the strongest predictor among process variables.

Better outcomes were achieved when patients were more compliant with their exercise program. This result has important implications for clinicians.

Ability to improve patient compliance is probably more of an educational skill than a clinical skill. One could perceive this as a marketing skill.

Physical therapists need to know how to educate and persuade patients that what they are “selling” actually works."

Daniel Deutscher and the folks at FOTO examined 22,019 people in 54 clinics in Israel over a two-and-a-half year period to see how the process of therapy affected the outcome of therapy. One of their findings was the association between exercise compliance and improvement.

If any non-physical therapists read this blog then that last statement could sound like a 'no-brainer' but physical therapist education does one thing very well - it makes believers out of physical therapists. We believe in the power of physical therapy to improve our patients lives.

Too bad physical therapy educational programs don't also provide training in 'selling' and 'marketing'. I'm thinking of calling up my alma mater and asking for my tuition money back!

The Israeli researchers are right - home exercise 'compliance' (I prefer collaboration) and adherence to scheduled visits separates the patient winners from the losers. Small setbacks can prevent patients from meeting their therapy goals- a painful flare up, arriving late due to traffic, the therapist changes the plan of care...

One telling example happened to me yesterday.

I employ physical therapist assistants - one of my PTA's asked a returning patient "How are you today?" the patient replied, "I'm sore from lifting at work" to which the PTA promptly said, "Well, let's put you on lumbar traction"...

• no neurological testing
• no leg signs
• no clinical rationale at all

...other than activity-induced lower back pain. The exercise program was aborted and traction was begun.

Why does the physical therapist culture encourage easy modality, massage and traction treatments when the accumulated evidence seems so heavily weighted against these interventions?

Why does it take a sample of 22,019 patients to show us the optimal treatments for persons with musculoskeletal injuries - when most physical therapists recognize the futility of modality therapy after six months on the job?

A 2005 study by Riddle and Jewell showed poorer outcomes associated with ultrasound and electrical stimulation therapy for sciatica patients.

Is there a way to break the physical therapy cultural modality mindset?

I think there is.

Make a culture of measurement.

Simple tools now exist that make measurement easy - easier than I had it in 1992 when I graduated with a Bachelors in Health Science, armed with Manual Muscle Testing to go forth and cure back pain and prevent folks from falling down.

No, physical therapy measurement tools are better now and we no longer have so many excuses for not knowing why the patient can't or won't get better.

Unfortunately, we are no longer in the driver's seat when it comes to determining our own fate or the fate of our patient's - government mandates are gobbling up therapy time with 17-page home health assessments and 30 minute outpatient therapy assessments - no time left for the patient.

I'm from the Government an I'm here to help

Government mandates are different from standardized assessments. Frequently, the government messes things up by trying to satisfy too many constituents.

We already have many good assessment tools:

1. Self Report measures
2. Performance measures
3. 'Old School' impairment measures
4. Classification measures

Fewer than 50% of physical therapists in the United States use outcome measures - that's like driving your car without a speedometer - with your eyes closed! No wonder modality treatments dominate therapists' thinking.

Sell the Outcome

We saved my traction lady.

She went back on exercise and functionally oriented training the next session, I gave her a follow-up questionnaire and she showed improvement over last week - traction did not help.

I asked her what she thought - she said she was sold on physical therapy.