How to Use Fear Avoidance Beliefs in your Physical Therapy Plan of Care

We recently held a Treatment Based Classification Seminar (TBC) at our physical therapy clinic in Palmetto, Florida.

Most of the physical therapists attending (14) had a fairly good awareness of TBC but one item stood out - Fear Avoidance Beliefs (FAB).

None of the attending therapists used even the FAB 'clinical shortcut' in their evaluation:

“I should not do physical activities which (might) make my pain worse.”

The clinical shortcut identifies elevated fear-avoidance beliefs early, so you could treat them. A number of seminar participants expressed interest in how physical therapists could screen for and treat patients' Fear Avoidance Beliefs in their plan of care.

• What are Fear Avoidance Beliefs and Behaviors?
• What techniques should physical therapists use when these findings are present?
• How can we help these people or should they be referred to medical providers?

What are Fear Avoidance Beliefs?

Fear Avoidance Beliefs are one type of psychosocial factors that include:

• depression,
• anxiety and
• job dissatisfaction,

...among other factors.

Persons experiencing an episode of acute pain are believed to manage the episode by 'confronting' the pain or by 'avoiding' the pain.

Persons who exhibit these 'avoidance' beliefs and behaviors are significantly more likely to experience disablement as a result of their acute pain.

How to Use Fear-Avoidance Beliefs in the Plan of Care?

1. Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a cool new tool that already fits the physical therapist skill set - although many of us may need additional training.

Some physical therapists may feel unprepared to render CBT but I would argue that the physical therapist is already well-suited to learn about CBT - it should complement our current 'toolbox'.

Cognitive behavioral therapy, within the context of our current practice, could be described as follows:

"Effective patient education by physical therapists appears to depend on the use of effective brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."

In other words, some of the same persuasive, coaxing, gentle, positive encouragement that most of us have used our entire careers to get patients more active.

Specific examples of some CBT techniques are as follows:

• keeping a diary of significant events and associated feelings, thoughts and behaviors;
• questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic;
• gradually facing activities which may have been avoided; and
• trying out new ways of behaving and reacting.
• Relaxation,
• mindfulness and
• distraction techniques are also commonly included.

George et al distinguished between the 'typical' educational approach of biomedical education and a fear-avoidance model of self-management.




2. Use FAB to screen for modalities

Childs et al found that use of electrotherapeutic or ultrasound modalities may encourage patients with elevated FAB to focus on their pain, avoid active 'confrontation' behaviors and lead to decreased outcomes.

Studies in America, Israel and the Netherlands tend to support the findings of poorer functional outcomes when modalities are used in the plan of care.

There is a significant chance that Medicare will decrease the relative value of modalities such as ultrasound or e-stim - even 'bundling' these modalities with other Common Procedural Terminology (CPT) codes, such as exercise, based on a lack of efficacy or effectiveness of modalities.


3. Predictor variable in TBC
   
   
   • Flynn's lumbar manipulation
   • Child's thoracic manipulation and
   • Hicks' lumbar stabilization rules
   
   ...all use the Fear Avoidance Beliefs Questionnaire as a predictor variable - lower levels of fear avoidance behavior generally predict successful outcomes. Hicks' stabilization rule is the exception - higher levels of fear-avoidance beliefs predicts success in this group.
   


4. Risk factor under a Medicare alternative payment system.
   
   Between 12-15% of the variation in the outcome of industrial workers' injuries was due to psychosocial factors, like FAB, not the physical or personal factors that physical therapists typically measure - like straight leg raise and Manual Muscle Testing (ugh).
   
   Since the payment by Medicare under an alternative payment system is likely to be a 'case rate' - say, $800 for 10 visits - anybody over the 10th visit is a financial risk to the provider.
   
   
   Physical therapists will need better measurement tools to identify these people, these outliers, early and perhaps apply for extra dollars.
   
   Screening for 'outliers' under an alternative payment system to Medicare Fee for Service will require sensitive tests to predict who is likely to need 20 visits for LBP, not 10 visits.

How can we cut costs and improve outcomes in physical therapy?

Since cost-cutting in healthcare is in the news recently I wanted to offer the physical therapist in private practice (PTPP) perspective - each cost-cutting measure is accompanied by a 'plus' (yes) or a 'slash' (no) according to whether or not I expect it to achieve its intended effect:


Health Information Technology (HIT)/Electronic Medical Records (EMR)

Most physical therapists will see a short run cost increase - don't be fooled by the price tag! Most of your costs will come in the form of time (if you are a small private practice) or altered workflows (everybody).

My experience with my EMR (which I am happy with) is a 3-4 month ramp-up time to build templates, change workflows, train workers and buy the accessory technology required.

Note that I am the primary physical therapist (with 2 PTAs) in a small (3,200 sq. ft.) office with three other employees. My face-time with the computer (not the patient) has increased with the EMR.

Nevertheless, the long run benefit of HIT is irrefutable. We all recognize the promise of computerization. Improved efficiencies, access to patient information and reduced provider burden (paperwork).

My EMR is a client-server model - I own the computer and I license the software for an annual maintenance fee. I paid $4,800 last year and I've done away with $300 in monthly dictation costs. Unfortunately, my dictation time went from 4 minutes to over 10 minutes. The accessory technology (server, PC-to-Fax, voice recognition software, etc) was another $7-8,000. Annual costs are probably less than $2,000 for maintenance and upgrades.

Unfortunately, there is no promise for improved outcomes for physical therapists since we don't prescribe medications and don't routinely read diagnostic imaging tests.

The APTA's position statement on HIT takes the prosaic view that we just need to 'hang in there' until physical therapists realize the benefits of improved technology but for now, the short run, computers and electronic records are just one more cost on your expense sheet.



Evidence Based Medicine (EBM)

EBM promises to improve patient centered outcomes, similar to improvements in acute pneumonia in community settings and acute chest pain in hospital ER's.

Pneumonia and acute chest pain were subjected to Clinical Decision Rules and Critical Pathways in the 1990s that mandated certain decisions at certain points based on certain criteria.

These high-cost, common conditions are amenable to 'quality improvements' by identifying the 'low-risk' patients that can be better managed at home or in outpatient centers. This allocates the system resources to better care for the high risk patients.

We don't have the studies yet to say that EBM lowers costs in physical therapy but several derivation studies have improved individual clinicians' decision making.

As with pneumonia and acute chest pain, several Treatment Based Classification (TBC) rules can identify patients who will NOT respond to physical therapy interventions and whose care is better managed with other techniques.

EBM may improve PT service volume if primary care doctors follow clinical prediction rules designed to identify low risk patients and order fewer expensive imaging tests.



Malpractice Reform

Physical therapists' malpractice costs are already already low (~$1,250 yearly for three providers in one 3200 sq. ft. office) - little promise for any improvements in PT practice expense.

Again, fewer primary care physicians ordering unecessary defensive diagnostic imaging tests may drive up volume for independent physical therapy practices. Better access to X-ray, MRI and CAT scans seems to drive up the rate of back surgery. A recent study in the journal Health Affairs shows that first time back pain patients get more surgeries in areas of above average MRI concentration.

The more important reform in medical malpractice reform might be the ability to renew a quality focus on 'systems errors' - the type that kill 100,000 patient annually - rather than on individual error.

This 2006 study from the New England Journal of Medicine found that 54% of the costs in malpractice settlements went to lawyers and administrative fees.

Few of these errors are the result of a single 'bad doctor' but on a fragmented system that is better at tracking procedure codes than individual patient outcomes.



Bundled Episode of Care Payments

Bundled payments are already saving costs and improving outcomes in a Medicare pilot project in five states. Lower infection rates and reduced hospital readmissions are the key outcomes measures in this project.

Many private practices feel that since the acute care hospital is the 'banker' the private practices may get the shaft.

The October 27th USA Today featured a story on the Medicare pilot program where one orthopedic surgeon was optimistic on it's success.

The surgeon named, Dr. Yogesh Mittal, received a 25% bonus for referring more patients to the hospital, which turned around and generated a 'slight profit' on 120 orthopedic knee and hip patients and 295 cardiac patients in 2009.

The physical therapy clinic named, Redbud Physical Therapy, does not participate in bundled episode of care payments since the program is only open to inpatient hospitals in 2009.

Redbud PT participates in the standard Medicare Fee for Service payment structure that is the mainstay of physician and therapy practices around the nation.

Jeff Jankowski, PT, ATC, Clinical Director & President of the Oklahoma Physical Therapy Association expressed some concern with bundled episode of care payments regarding the private practice PT clinic,

"I just don't think there's enough information yet", he said.

Jeff, I think you're right.

The International Classification of Functioning, Disability and Health (ICF)


The new ICF alters the way providers think about rehabilitation and disability. The ICF takes physical therapists away from the (dysfunctional) medical model and casts health in a framework centered on the person and what they can do and what they are able to do.

The ICF is not revolutionary - it's evolutionary.

The ICF was adopted in May 2001 by the World Health Organization (WHO) and the APTA in June 2008 as a framework for measuring health and disability at both individual and population levels.

The ICF shifts the focus away from the pathology and puts our attention on the person.

"By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability.

Furthermore ICF takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction."

Placing physical therapists into the role of the primary rehabilitative decision maker is an added responsibility but also an opportunity.

This new emphasis may encourage physical therapists to make decisions like doctors.

Developing Outpatient Therapy Payment Alternatives

The new Medicare 17-page PT evaluation form with 8 pages on 'Provider Information' that contains nary a validated test or evidence-based predictor rule puts the lie to the assertion that any new alternative payment system will cut costs or improve outcomes - at least in a way that is obvious to those of us outside of Research Triangle International's Technical Expert Panel (TEP).

Outcomes from another 17-page PT evaluation form are already being collected by the home health physical therapy Outcome and Assessment Information Set (OASIS) in the form of 'per cent improved'. The outcomes are ranked by state .

Any alternative outpatient PT payment system will likely be a case rate (eg: $800 for 12 visits) with extra dollars for 'risk adjusted cases' that show up as outliers (eg: 20 visits instead of 12). How physical therapists identify these outliers initially will be important.

Probable risk factors for therapy outliers include:

• age,
• psychosocial variables (fear, anxiety, depression)
• prior surgeries,
• disability scores, etc

Measuring these risk factors could be a sustainable competitive advantage for therapists competing against other providers like physicians and athletic trainers. The problem with the new Medicare PT eval form is that it doesn't seem to emphasize these factors.

The promise of the alternative payment system will be to cut long run Medicare costs and improve outcomes by moving away from a Fee-for-Service based payment system.

Unfortunately, a 17-page PT eval is going to feel time a short-run time cost to most of us.

Medicare Experts Recommend Physical Therapists Get a Comparative Billing Report

We've just completed the Classification Seminar with Special Guests Jim Needham, former CEO of a local physician owned physical therapy (POPTs) clinic and Belinda Holmes, healthcare auditor for accounting firm Kerkering Barberio on Saturday, November 7th.

Our audience of physical therapists and physical therapist assistants was very interested in Jim's talk:

"Competing with POPTs under Healthcare Reform"

We will have Jim's audio and PowerPoint available very soon. Also, Jim is being interviewed by Jeff Worrell on PT Talker this Friday the 13th.

Belinda had many good recommendations for physical therapists in private practice (PTPP) to build a Medicare compliance program in her talk:

"Medicare Defense Strategy: The RAC Attack"

The #1 question asked by our audience members after the seminar was on one topic raised by Belinda.

Belinda recommended that private practice owners get themselves a Comparative Billing Report from your local Medicare carrier - here in Florida your Medicare Part B carrier is First Coast Service Options.

You need to write a letter on your letterhead and request a specific six-month time frame for specific providers identified by National Provider Identifier (NPI) number.

Sorry, this option is not available for those providers billing as groups or 'incident to' the physician services (POPTs).

Here is the contact info for the Florida Medicare Part B carrier.

Statistical and Medical Data Analysis (phone: 904-791-8006)

First Coast Service Options
Statistical and Medical Data Analysis
P.O. Box 44288
Jacksonville, FL 32231-4288

There is no fee for providing these reports.

New seminar scheduled

Send in your application now for our next scheduled Classification Seminar on November 21st. You can apply here.

Private Practice Physical Therapists will get RAC data from Belinda Holmes

Belinda Holmes, BS, CPC, CCP-P will share her physical therapy RAC 'war stories' and tips to protect yourself from physical therapy automated claims review for 'untimed codes' in 2010.

Belinda will present

"Medicare Defense Strategies"

in Palmetto at Medical Arts Rehabilitation, Inc from 9am to 3pm - Belinda's part begins at 10:30am -11:30am on Saturday, November 7th, 2009.

Belinda works for Kerkering Barberio, a large Sarasota accounting firm with expertise in defending physical therapy clinic owners from Medicare audits.

Belinda is usually called in after the audit letter is received by the physical therapist and by then her job is usually 'damage control'.

At her seminar, Belinda would like to share with you ways to prevent that audit letter from ever reaching you.

Belinda's talk will focus on real-world, 'boots-on-the-ground' tactics you can use in your daily practice to prevent and defend your notes and charts from a Medicare audit.

1. RACs: What are they and how to avoid them
2. OIG 2010 Work Plan
3. Real life accounts of physical therapy audits
4. The new focus on medical necessity

Recent RAC missteps

RACs have not been putting up the kind of stellar numbers recently that earned their Demonstration Project permanent status in 2008.

The latest update of the three year Demonstration project in Florida, California and New York reveals that providers are right to have concerns about RAC improper application of Medicare guidelines.

Type of Reviewer	% of improper payment denials appealed by provider	% of appealed claims overturned in favor of provider	% of all improper payment denials overturned in favor of provider
Claims Processing Contractors	4%	59%	2.3%
Recovery Audit Contractors	22.5%	34%	7.6%

Since the percent of all 'improper payment denials' for RACs is almost three times the rate of MACs the data lend credence to the belief that RACs are not correctly interpreting Medicare guidelines.

Since RACs return overpayments successfully overturned at any level of the appeals process what can providers do to create a strong disincentive for RACs to incorrectly deny your claim?

Appeal!

Call 941.729.1800 to RSVP for Saturday's seminar.

You can get more information at www.BulletproofPT.com

Docs won't be able to own physical therapy, says Jim.

Physician Owned Physical Therapy (POPT) clinics may be on the way out in 2010 says Jim Needham, CEO.

Jim will present his seminar...

"Competing Against POPTs under Health Care Reform"

...in Palmetto, Florida on November 7th and 21st.

Jim Needman is a healthcare consultant and former POPTs CEO so he should know what he is talking about.

Jim's main premise is that physician practices will be unable to comply with new requirements in owning physical therapy clinics.

So you know a little bit more about Jim, here are some of his credits.

• Managed over 800 physicians across the United States
• Managed PT within several physician practices
• Most recently was the CEO of a 17 Orthopaedic and Pain Management practice
• 3 PT sites representing 20 therapists and assistants
• Worked for private practices and practice management corporations
• Closely monitoring ObamaCare and its effect on reimbursement and ancillary services ownership by physicians (includes; PT, MRI, ASCs, and others)

Jim says there is a 33% POPTs will be ruled illegal within three years - he bases his prediction on 'increased transparency and compliance requirements' large and small POPTs will have to meet under rules passed October 1, 2008.

The seminar is one hour - from 9am to 10am to be held in Palmetto, Florida at Medical Arts Rehabilitation, Inc. physical therapy clinic.

Immediately following Jim's presentation Belinda Holmes, CPA from Kerkering/Barberio will present

"Medicare Defense Strategy for Recovery Audit Contractors"

Some of Belinda's talk will include:

• RACs: What are they and how to avoid them
• OIG 2010 Work Plan
• Real life accounts of physical therapy audits
• The new focus on medical necessity

Finally, Tim Richardson will present four hours of Florida CEUs on

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

Dates: Saturday November 7th OR Saturday November 21st

ConEd units: Four (4) hours CEUs from Florida FPTA.

Cost:

• $175 Early Bird discount (5 days prior to your selected date)
• $200 after the deadline or on-site registration.

Come to the seminar prepared to do the following:

• discover the role of POPTs in 2010
• lern how to protect yourself from RACs
• learn treatment based classification (TBC)
• practice new hands-on skills training
• apply evidence based techniques to physical therapy patient care
• improve your decision making
• make a physical therapy diagnosis

Call 941.729.1800 to ask for a course brochure or sign up by phone.

Credit cards, checks and cash accepted.

You can also sign up on-line at BulletproofPT.com and pay with PayPal.

If you want to succeed in private practice in 2010 you don't want to miss this seminar!