"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

Thursday, November 12, 2009

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:
minus sign for health care

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.

plus sign for health care

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.

minus sign for health care

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.

minus sign for health care

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)

plus sign for health care
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.

minus sign for health careDeveloping 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.

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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 .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
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