A little help with Health Care Reform

I don't know if we know exactly how this new law will impact private practice physical therapists but this video gives a short, entertaining look at the timeline in a way that breaks down the objections on both sides of the divide...

Thank you to the good people at the Center for Medicare Advocacy, Inc.

Physical Therapy Abuse by Miami Physician

I have two boys: seven and nine years old. When they start getting too fussy, I "separate" them and send one boy outside and the other boy to a friends' house. That seems to prevent the inevitable conflict.

Physicians and physical therapists involved in Medicare fraud seem to invite similar negative results.

This recent (Dec. 22, 2010) Wall Street Journal article highlights the dangers of physician-owned physical therapy (POPTS) as well as outright fraud by self-employed physical therapists.

This map, created by journalists at the Wall Street Journal (WSJ), show physical therapy billing "hotspots" in the USA: Miami, Houston and New York City.

The WSJ article goes on to describe physicians in Miami and Houston billing for physical therapy services and a physical therapist in New York billing $2.5 million to Medicare in a single year.

Maybe we should separate physicians and physical therapists?

One solution is to outlaw physician ownership of entities to which they self-refer (eg: physical therapy, clinical laboratories, imaging centers, etc). This only seems reasonable to most people.

The situation in medicine and physical therapy is that 1% of the providers give the other 99% of us a bad name. The opposite situation exists in politics where 99% of the politicians give the rest of them a bad name:)

The Federal government figured out the self-referral situation in 1989 (Starke I) and extended the anti self-referral rule to Medicare in 1993.

But, concerns that government was intruding too far into medicine and legitimate business arrangements allowed doctors to apply "exceptions" for in-office physical therapy services in 2005.

This Rock-n-Roll doctor took $1.8 million in Medicare in 2008, much of it from physical therapy, shake-n-bake treatments he prescribed for his patients.

The treatments were not done by physical therapists but by "office girls" that he "trained" himself. Medicare caved-in to POPT physician pressure when they wrote Federal licensure requirements:

"Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure."

Another solution is to step-up anti-fraud efforts.

However, Recovery Audit Contractors (RAC) audits of providers find that inpatient hopitals, not Nigerians or Rock-n-Roll Doctors, are the largest source of cash to the RAC revenue generation scheme.

Inpatient hospitals are likely targets, not because of outright fraud, but because the system is too complicated, medical billing too technical and billing errors the result of mistakes not crime.

Who commits most of the crime in Medicare fraud?

It's not providers. It's not even fancy rock-n-roll doctors.

60% of healthcare fraud is due to the pharmaceutical industry and insurance companies.

Industry	Recovery(millions)	Per Cent
Healthcare Provider	$2,122.25	38.8%
Insurer	$890	16.3%
Pharmaceutical	$2,459.75	44.9%
Total	$5,472.00	100.0%

My kids don't know when to separate themselves so I do it for them and we keep peace in the family. How can we keep "peace" in our adversarial Federal healthcare system?

If we can't separate physicians and physical therapists then what about removing the requirement for the physicians' signature on the physical therapists' Plan of Care?

Isn't that the source of the conflict?

Physical Therapists Find Difficult-to-Diagnose Pathology Better Than X-rays

In physical therapy school, they taught me that "objective" test findings are those not colored by patient bias.

We ask the patient for their "subjective" report that we, as medical experts, need to validate through the diagnostic process.

But, "objective" tests may be biased also.

X-rays are commonly referenced to illustrate the difficult dichotomy between "soft", subjective data and "hard", objective data.

When we make decisions we would like to have the high quality data, and then, if possible, consider other, lower quality data.

In diagnosing an x-ray, radiologists decision making is made up of two parts: Perception and Cogniton.

Perception is the physicians' eyesight, image quality, stage of pathology, training, experience, and possibly the prevalence of the condition in the population. These are all well-measured factors that we train in medical school, certify by government agencies or enforce through legal practice standards.

Cognition is less well-measured. Cognition varies by individual and, within individuals, cognition varies by time of day, mood, fatigue, knowledge of other patient factors, stress, time frame of the decision, setting of the physician and other "soft" factors.

Radiologists and X-ray Findings

Radiologists have a difficult job. In one study of mammography, their inter-observer reliability was only 48%. That's "moderate".

See this Medscape slideshow of difficult-to-interpret X-ray images of the lung.

Slide 13 of Easy-to-Miss Findings on Chest Radiographs shows a wedge thoracic compression fracture that can be missed on x-ray imaging.

A newly published decision rule by Henschke enables physical therapists to screen for vertebral fractures without the need for expensive and irradiating images.

Slide 14 of Can't Miss Critical Findings on Plain Chest Radiography shows a pulmonary emboli that broke off from a deep vein thrombosis in the leg.

"Of note, most chest radiographs are normal in patients with a pulmonary embolism".

Physical therapists can detects thrombotic blood formations before they turn into a hard-to-catch, deadly emboli using Well's criteria that will find blood clots with greater sensitivity that a physician's clinical intuition.

Physical Therapists' Findings

Even commonly used physical therapists' tests traditionally described as "objective" are less than helpful. Commonly used tests taught to orthopedic manual therapists for sacro-iliac dysfunction and SLAP tears have little predictive value.

In some cases, a negative test may be able to rule out the condition but cannot confirm the diagnosis. Physical Therapists Chad Cook and Eric Hegedus have written this excellent book to clarify some of the issues surrounding diagnostic accuracy.



However, some "subjective" tests are reliable most of the time. Consider that the test-retest reliability of the Oswestry Disablement Index is 0.99. Almost perfect.

In the proper selection of "objective" physical therapy tests and measures patient bias seems to be less likely than clinician bias.

California Physical Therapists Face New Challenges

There may be a opportunities for California physical therapists to purchase their employer physical therapy clinics for pennies on the dollar after a new ruling by the State of California Legislative Counsel found that physician-owned physical therapy clinics (POPTs) are illegal in California.

This ruling developed from stalled 2009 legislation put forth by podiatrists to add physical therapists to the list of professionals allowed to be employed in medical practices.

Physical therapists are currently NOT on the list and, as a result, the recent Legislative Counsel ruling determined that their participation in these businesses is illegal.

"The existing California Corporations Code does not specifically include physical therapists on the list of those who may be shareholders, officers, directors, or professional employees of medical, podiatric or chiropractic corporations.

In 2009, Assembly Bill (AB) 1152 was brought forward by the California Podiatric Medical Association to determine the legality of podiatrists owning a physical therapy practice.

They were later joined by the California Medical Association and California Chiropractic Association.

Assembly Bill 1152 would have amended Section 2406 of the Business and Professions Code and Section 13401.5 of the Corporations Code to add licensed physical therapists to the list of healing art practitioners who may be shareholders, officers, directors, or professional employees of medical, podiatric or chiropractic corporations.

CPTA strongly opposed AB 1152 because the legislation would have made it legal for medical, podiatric and chiropractic corporations to employ physical therapists.

In effect, under this legislation, these corporations could control the point of access to physical therapist services and then refer patients only to themselves.

This type of arrangement poses an inherent conflict of interest and removes choice for the consumer.

On July 13, 2009 the members of the Senate Business Professions and Economic Development Committee understood the potential conflict and did not pass the bill.

The opinion from Legislative Counsel confirms that, because the California Corporations Code does not specifically include physical therapists on the list of those who may be employed by a medical corporation, a physical therapist is prohibited from providing physical therapy services as an employee of a medical corporation and may be subject to discipline by the Physical Therapy Board of California for doing so."

According to the California Physical Therapists' Association (CPTA) employee physical therapists have three options:

1. Buy out the practice
2. Become an independent contractor
3. Find new empoyment

The CPTA has laid out these options in the CPTA Employment Toolkit to help affected therapists transition to new business arrangements.

As an independent physical therapist involved in Government Affairs in Florida I watch events like the California decision with keen interest.

Is this way the right way?

Does the California decision improve their position compared to the position of physical therapists in South Carolina?

Is the California approach better than the approach taken in Washington state?

Dangers of NSAIDs - no side effects of physical therapy!

Thanks, ZDoggMD, for spreading the word on excessive NSAID use.

Here's the good doctor's entertaining and educational video:



Putting a human face on medicine, making people laugh and educating people is EXACTLY what doctors and physical therapists need to be doing!

Great work, ZDoggMD!

With Great Power Comes Great Responsibility

...these are the words of Dr. Donald M. Berwick, Administrator, Centers for Medicare and Medicaid Services on October 5th, 2010 as he was wrapping-up a workshop on Accountable Care Organizations in Baltimore.

Dr. Berwick was quoting Spiderman, trying to motivate and incentivize the gathered healthcare providers, attorneys, corporate executives and other stakeholders trying to figure out what the new rules of the game will be from the largest single purchaser of healthcare services in the world.

There is currently much interest among physical therapist private practices in the new Accountable Care Organizations that Dr. Berwick sees as new "...care delivery organizations, not as financing mechanism...".

Yet, there is little reassurance for private practitioners at the bottom of the referral nework that hospitals and large physician organizations will share the gains equitably if they become the "bankers" of the new ACO.

Ten years of research shows that physical therapy reduces costs and improves outcomes for high cost drivers like lower back pain.

Are there any assurances that physical therapists will become primary care providers for these patients? Won't hospitals have the incentive to under-treat these patients?

CMS is betting the farm on the cost-saving features of ACOs and counting on some, as yet undefined, quality measure to prevent undertreatment by hospitals.

Dr. Berwick finished up his speech by saying...

"Let me be clear, in closing, about one final, serious matter: authenticity.
Authenticity matters.
Those who wish only to preserve the status quo are not going to be constructive contributors to our nation’s future.
They cannot be effective partners, and we simply do not have time to pretend that they are.
We just do not have time for games anymore."

Tough talk - I like that - except that, when ACOs do arrive in two years, Spiderman won't be here to save us.

Urologists Self Refer Cancer Patients and Drive up Medicare Costs

Physical therapists will be familiar with the downside of physician self referral since medical specialties which use lots of physical therapy started bringing therapy clinics in-house in 2006 when clarifications to the Stark 2 "In-Office Ancillary Services Exception" were published in the Federal Register.

Now its urologists turn to stand in the spotlight thanks to this Wall Street Journal article and video interview exposing these self-serving practices.

The article focuses on a $40,000 treatment known as Intensity Modulated Radiation Therapy (IMRT) which is an aggressive and expensive option for a disease that may not kill you until you're 120 years old.

Unfortunately, by then Medicare will be insolvent - perhaps due in part to the rapid rise in costs from IMRT treatments.

This video describes shows the sales pitch delivered by a company marketing the technology to urologists:



Dr. Gerald Chodak of Medscape speaks out against urologists' practice of self-referral.

I wonder why we don't see any orthopedists or neurosurgeons speaking out against self-referral?

Do Physicians Make Decisions Based on Financial Factors?

Dr. Gerald Chodak of Medscape questions that treatment decisions made by urologists who own the equipment and do intensity-modulated radiation therapy (IMRT) for localized prostate cancer may be influenced by financial factors.

Dr. Chodak says,

"For physicians who do radical prostatectomies, the net profit is between $2,000 and $3,000, depending on who is paying for it.

Active surveillance doesn't pay nearly as well."

Dr. Chodak recommends a "constant fee" - no matter how the patient is treated.

I wonder how a constant fee would work for physical therapists?

See the page and the doctor's comments at Medscape.com.

Physical Therapy in the Prevention and Treatment of Osteoporosis

Osteoporosis might not have the public spotlight like many other widespread diseases, but it’s a serious problem for over 75 million people in the U.S., Europe, and Japan.

The International Osteoporosis Foundation states that one in three women and one in five men over the age of 50 will experience osteoporotic fractures – so why don’t preventative measures and treatments get more attention?

Based on the number of individuals affected by this serious disease, there should be an equally large demand for information, supplements, treatment options, and physical therapy and exercise regimens.

But because osteoporosis is a silent disease, only those who are suffering from its worst complications are aware of it. Fortunately, physical therapy can help treat some of these complications – and it can also help to prevent osteoporosis.

Although it’s not the first form of treatment that tends to pop into someone’s head when the word “osteoporosis” is spoken, it’s highly effective and has been proven to be one of the best courses of action against the disease.

How Physical Therapy Fights Osteoporosis

For those who already have the disease or are at risk for developing it, physical therapy is often a recommended form of treatment – and it can even be practiced on patients who have sustained fractures.

A patient’s road to beating or managing osteoporosis begins with a thorough evaluation, enabling the physical therapist to identify an individual’s activity limits. This is based on a close study of the patient’s bodily movements that shows imbalances, restrictions, and both what the patient is capable of doing and what is obviously beyond his or her limits. The physical therapist then takes this information into consideration while drawing up a customized program for the patient.

Physical Therapy Program Components

A patient’s physical therapy program might be comprised of prescribed exercises, pain management through heat and ice, massage and manual therapy, bone-strengthening activities like tai chi and yoga, and other types of weight-bearing exercise.

There are several important components of exercise in physical therapy because osteoporosis can be a delicate disease to treat.

Exercises should be weight-bearing to build bone mass and strengthen bone-supporting muscles, but this type of exercise alone can be detrimental to someone who’s already experiencing the fragility caused by osteoporosis. To counter this, physical therapists employ exercises that teach patients about body balance, mechanics, and posture – these types of exercises ease the stress on bones to reduce the risk of new fractures.

Good balance and posture are also essential to preventing falls, which are the cause of many fractures. Exercises that promote flexibility (such as yoga and tai chi) and working to improve patients’ gaits are additional concerns that physical therapists include in each exercise program.

Consultation and Patient Responsibility

Finally, physical therapists consult with their osteoporosis patients to identify potentially harmful activities at home or at work.

Many patients struggle with fear of sustaining fractures and limit their daily activity more than they need to. Physical therapists can help these patients to gradually build activity back into their lives by showing them which types of activity are healthy and what might be considered risky activity. Patients may even be reluctant to practice exercises at home because of their fear, but it’s important to follow the physical therapist’s instructions to the letter.

Even with the most successful physical therapy program, patients are ultimately responsible for practicing the prescribed exercises at home and avoiding any activity that might increase their risk of osteoporotic complications.

Patients can also supplement their physical therapy treatment plans by increasing calcium, vitamin D, and vitamin K intake – all of these contribute to the process of building or maintaining bone mass. When combined with the appropriate forms of weight-bearing exercise, supplements like these can promote optimum bone mass growth, which is an important part of treating and preventing osteoporotic complications.

Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education, where recently she's been researching different physical therapy assistant schools and blogging about student life. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.

Why I Couldn't Participate in the DOTPA Pilot Study

I can't use the DOTPA self-reports for care planning and goal setting in my outpatient physical therapy clinic.

The 17-page evaluation and the 16-page discharge note are not intended to be a part of your patient's clinical record. You are not expected to make clinical decisions based on the data recorded.

I can't use the AM-PAC (from which DOTPA is derived) without paying the license fee. The folks at Research Triangle International (RTI) offered to see if the AM-PAC was available, in the full, commercial version, for data collection - but, it was not.

I am not alone. Researchers associated with the RTI project have objected, on scientific grounds, that the DOTPA project...

"...developed a proposal that demonstrated a scientifically deficient and naïve review of existing instruments available for patients receiving outpatient therapies."

Specifically, the researchers charged, the DOTPA tool is less...

"...sensitive to change (than competing measures) and since payment might be based on these measures, it is essential to have the most sensitive measure for the clinicians to gain the most reimbursement when warranted."

I can't ask my therapists to perform "double entry" for several reasons:

1. My profit margins not sufficient to support the administrative burden.
2. Studies of paper-based and computerized Clinical Decision Support systems show that "double entry" is a major source of system failure.
3. My patients would object.
4. Pen-and-paper measures are a step backwards in this era of computerization, automation and electronic decision support tools.

Our Medicare Compliance plan is based on the following:

• data-driven decisions
• setting quantitative goals
• knowing when minimal change occurs to demonstrate progress
• knowing, based on quantitative progress scores, when to apply the -kx modifier for patients eligible to exceed the $1,860 PT/SLP cap

Using the DOTPA tool would not only have imposed expensive and time-consuming burden on my therapists but my physical therapy notes would have become LESS COMPLIANT for Medicare.

Who can use the DOTPA tool?

Interesting story.

I invited a friend and a peer to listen in and share notes on my phone line to the original RTI conference call on August 19th, 2010.

She was using, at that time, NO outcome measures - for her the DOTPA project was a step in the right direction.

Can You Put a Number on Physical Therapy?

One of the most popular Simpsons episodes ever - MoneyBART - succinctly describes the struggle between intuitive and algorithmic decision making in physical therapy.

(video length 2min 50sec.)


This struggle, catapulted to prominence in 2002 with the publication of Flynn's manipulation rule, is not unique to physical therapists.

Physicians, too, resist the influence of decision rules and adhere poorly to clinical practice guidelines.

Physical therapists share some commonalities with physicians in that we overestimate our ability to access medical knowledge relevant to the patient, to screen for low-frequency events and to apply effective treatments while mitigating the use of ineffective treatments.

MoneyBART captures what I think is one of the drivers for the low utilization of evidence-based decision rules (including treatment-based classification). This driver is captured in the struggle between Lisa and Bart.

Lisa argues for numbers and statistics - the "brains" of the algorithmic, "computer logic" behind treatment based classification - while Bart argues for his "gut" - the intuitive, naturalistic basis for pattern matching traditionally employed by physical therapists.

Plot synopsis: Lisa becomes the manager of Bart's Little League baseball team even though she doesn't know anything about baseball ("Go kick a field goal, Bart!").

To learn about baseball, Lisa turns to a team of statisticians who meet to discuss sabremetrics at Moe's Tavern. Using this brand of statistical baseball analysis, Lisa begins winning games and Bart complains that she has taken the fun out of the game. Bart gets kicked off the team after disobeying Lisa's instructions to walk off a pitch and hits a home run, winning the game.

Lisa eventually makes the city championship and she asks Bart to come back because she needs Bart to pinch run from first base. He agrees to help but again disobeys her management and tries to steal all the way home. As Bart makes his move, Lisa calculates the odds as being vastly against him but, instead of being mad, comes to love the thrill and excitement of the game. Bart is tagged out at home, losing the game and the championship, but Lisa thanks him for showing her how to love baseball as a game.

In fairness, I've made some simplifying assumptions that physicians and physical therapists resist clinical decision support (CDS) because of personal factors ("It takes the fun out of the game") when, in fact, clinicians are professionals who may resist the "top-down" management of complex doctor-patient interactions they perceive as limiting.

Physicians typically not trained, incented or supported for using evidence-based decision rules. The rational response, then, is not to use them.

But, we do have good evidence that safety and efficiency, from high-quality impact studies, are both improved when algorithmic decision making replaces intuition.

Does that take the "fun" out of the game?

Medicine isn't Little League so, if we're going to play, let's play to win.

Leverage Points

Physical therapists can "leverage" their expertise to spot opportunities that physician may miss. This takes training, experience and an attention to detail - attributes that many physical therapists possess in abundance.

Here's how "leverage" works in the physical therapy clinic...

Betty Love came to my physical therapy clinic last week with a referral from her orthopedic surgeon for rehabilitation after her right total knee replacement.

Betty is...

• two weeks post-op
• walks with a four-point walker
• has some swelling
• redness and
• incisional tenderness.

Betty has high expectations, is willing to work hard and a good listener.

Betty is a satisfied physical therapy patient from a prior episode of lower back pain about one year ago.

Betty filled out some questionnaires in the waiting room at her first visit:

• Fear Avoidance Beliefs (FABQ)
• Knee Injury and Osteoarthritis Outcome Score (KOOS)

Tests similar to these are routinely filled out by patients at Medical Arts Rehabilitation, Inc. for care planning and goal setting.

When asked, Betty indicated that she would NEVER consider kneeling on her operated knee even though her surgeon chose a prosthetic that allows kneeling (Oxford PKR by Biomet).

Betty stated that she had not knelt for many years before her surgery and why would she want to kneel after her surgery?

A study by Jenkins published in September 2008 in the Physical Therapy Journal revealed that patients will NOT spontaneously learn to kneel after partial knee replacement (PKR) unless trained to do do.

After PKR, without training, the patients who could NOT kneel increased from 28% of patients to 34% of patients!

Joint replacement surgery actually made these patients MORE disabled!

Physical therapists can improve other activity limitations (eg: heavy household chores, getting up off of the floor, etc.) by training kneeling.

Patients do NOT Value Kneeling

Like Betty, many patients in physical therapy have voluntarily restricted their daily activities due to pain, fear-of-pain, low endurance, depression or lifestyle.

In the 2003 study detailing the KOOS scale, researchers found that over 90% of patients wanted improvements in Pain, Symptoms, ADLs, and Quality of life after surgery while only 51% of patients reported that improvements in squatting, kneeling, turning and twisting were very important.

Can Kneeling Predict Future Risk?

Ganz, Bao, Shekelle and Rubenstein describe a "quantitative approach" to falls risk assessment that provides the probability shift associated with many physical findings such as the following:

Physical Exam Test	+ Likelihood Ratio	Estimated Probability Shift
Inability to do 1x Chair Raise w/o arms	4.3	+25%
Inability to do 1x Chair Raise less than 10sec.	2.3	+15%
Inability to do Tandem Standing for 10sec.	2.0	+15%
History of falls in the last month	3.8	+25%
Osteoarthritis of the knees	2.0	+15%
Slower Gait over 10m.	2.0	+15%

Positive physical examination tests for faller status are sensitive but not specific, that is, they don't accurately predict non-faller status. Although kneeling has not been studied may other common physical therapy interventions have been studied. This table illustrates how a positive test (eg: disability) is more predictive than a negative test.

Gary Klein, PhD describes leverage points that only experts recognize as opportunities to intervene while the outcome is uncertain, undetermined or unlikely (p.116 Sources of Power).

Experts recognize a need as well as a sense of how the problem can be solved. Leverage points are important because experts can apply their skill to effect change early in the course of care, at less cost and with better outcomes.



Physical therapists can prevent patients like Betty Love from falling down, becoming institutionalized, experiencing chronic disability and pain by recognizing "leverage points" that non-experts like physicians, patients and family members do not recognize.

Physical therapists will need to have the courage to challenge patients values, physicians expectations and payers' "rules".

But, I'm optimistic since courage is something physical therapists have in abundance.

New Veteran Administration Study Positive on Physical Therapy Rehabilitation

A recent meta-analysis of Veterans' Administration (VA) care compared with non-VA care found the VA performed better on process measures but about the same on patient outcomes.

Rehabilitation fared well in the Systematic Review: Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings. One of the 36 studies that passed the final cut looked at rehabilitation outcomes and assessed 60 post-stroke patients, finding good outcomes:

"...Stroke patients receiving rehabilitation in VA settings were discharged with better functional outcomes..."

Limitations of the study reported in the media were the use of self-report measures of outcome, typically questionnaires or patient interview.

Many newer data indicate that reliability of self report is superior to more traditional "objective" data but older clinicians, some physicians, politicians and the lay public may have difficulty understanding why the Oswestry Disablement Index returns "harder" data than a lumbar x-ray in the assessment of lower back pain:

"PROs are often not included in routine clinical care or quality improvement activities because some clinicians believe that PROs are not "objective" measures or that they lack precision for measuring individual patients." - Darren DeWalt, MD

Another criticism was the age of the studies - most dated from the Clinton administration and one study was from 1991.

The VA performed well on process measures such as issuing the right medication at the right time to the right patient. The VA's performance on patient outcomes, however, was not so good:

"Studies that used accepted process of care measures and intermediate outcomes measures, such as control of blood pressure or hemoglobin A1c, for quality measurements almost always found VA performed better than non-VA comparison groups.

Studies looking at risk-adjusted outcomes generally have found no differences between VA and non-VA care, with some reports of better outcomes in VA and a few reports of worse outcomes in VA, compared to non-VA care."

The media seem perplexed by these results but most physical therapists will recognize that health care, as a determinant of health, accounts only for about 10% of the causes of death and disability:

Veteran's Administration outcomes are a hot topic right now because of their own public relations campaign over the last fifteen years promoting their investment in Electronic Medical Records (EMR) and automated Clinical Decision Support (CDS) technology.

This meta-analysis may be seen by some as a testimony to the effectiveness of that investment.

“This report is strong evidence of the advancements VA continues to make in improving health care over the past 15 years,” said Secretary of Veterans Affairs Eric K. Shinseki.

“The systems and quality-improvement measures VA actively uses are second to none, and the results speak for themselves.”

Some of the reasons proposed for the VA's superior performance in processes of care include the following:

• integration of health care settings
• use of performance measures with an accountability framework
• disease-management practices and electronic medical record or health information technology.

Physical Therapy Price Innovators Hated by Everyone

$68 visits for physical therapy in Michigan have some private practice physical therapists hoping Theramatrix loses its fight to treat Ford and Chrysler workers with Blue Cross Blue Shield (BCBS) of Michigan.

The Justice Department, however, views BCBS actions with hospitals to keep competitors from seeing the Ford and Chrysler workers by charging up to 40% for the same treatments, like physical therapy, as anti-competitive.

Is it hard to tell who to root for?

On the one hand, TheraMatrix Physical Therapy, Inc. has organized a provider network to compete against the monopolistic Blue Cross franchise and bring prices down to $68 per PT visit.

Isn't that the goal? To bring healthcare costs down so employers can offer affordable coverage eventually to everyone?

On the other hand, Michigan private practice PT owners are openly hoping for TheraMatrix to loose its battle and, ultimately, its revenue stream and go out of business.

$68 per visit, according to some PT thought leaders, is insufficient revenue per visit to run a private practice.

I would agree - under our present system with many hidden costs, compliance and administrative burdens, malpractice risks and increasing healthcare labor costs.

My costs here in Florida are about $68 per visit. We used to take United Insurance which is like giving every patient with that insurance a $20 after each treatment session.

However, physical therapy is flourishing around the world - in countries that DO NOT HAVE our hidden (and non-hidden) compliance costs.

Physical Therapists in Spain have full direct access, charge about $35 per visit and collect cash.

Oh, and by the way, private practices are flourishing with brand new clinics every time I go and visit. Spanish physical therapists also don't face competition from physicians.

Low payments are a problem in American healthcare because current owners of capital need those payments to meet expenses, including profit.

What gets missed in this discussion, however, is that the hidden costs of compliance is what is preventing innovation and lower costs.

TheraMatrix has produced innovation pricing and put itself in a head-to-head confrontation with everyone in Michigan: BCBS, hospitals and PT private practices.

What if, instead of innovative pricing we had innovative service delivery? Things like...

1. distance therapy by e-mail reimbursed
2. video home exercises
3. mixed home and clinic based therapy from a single provider
4. therapist deciding medical necessity instead of the physician
5. no need for the physician signature on the plan of care
6. therapist deciding of appropriate delegation to support staff (including PTA and non-licensed staff).
7. simple, inexpensive standards for outcomes measurement
8. benchmarks for progress according to these standards

Many of these concepts currently exist but they are NOT part of our service delivery model, especially under Medicare.

The problem, then, is that our current system rewards ONLY price innovation and not service delivery innovation.

It's not rocket science - the only way to innovate on price is DOWN and the innovators, like TheraMatrix, are hated by everyone.

Standards in Physical Therapy

This question came up from an interested reader and I'm re-posting it here to provide a forum for discussion. Let me know if you have any other questions along these lines...

Dear Tim,

"Are there specific standard functional levels for post acute cure patients in deciding what level of care is optimal for these patients:

• In Patient Rehab
• SNF
• HH
• Hospice
• Outpatient Service?

I do understand there are multiple considerations in this decision making process as well as the payer coverage and patient/family desires/considerations... however I wondered if there were standards available.

I would appreciate any insight into the deliveries of care."

Thank you,
NM

Dear NM,

You've brought up a great point: Are there standards for post-acute care for physical therapy patients? My experience is in outpatient delivery but these suggestions should be applicable to any ambulatory, post-acute setting.

Your question is rather broad so I'll take the liberty of addressing a specific portion - should we change over the course of care or discharge functional status?

This issue, incidentally, also begs the question of how to assess baseline status, medical necessity for physical therapy and progress in an expected time frame required for Medicare reimbursement.

At this time, a lot of work is being done assessing change over the course of care: you can do this work yourself using validated change scores like MCID or MDC for patient self-report (eg: ODI, LEFS, NDI...) and performance scales like Step Test, 10' Gait Velocity, et al.

You can also pay to have it done for you by groups like FOTO, AM-PAC or even DOTPA (you pay with your time).

Is there a standard for discharge function?

Not really.

Lots of groups have published age-and-gender matched norms for their tests (eg: Cybex, MedX and even tests like Single Leg Support) but these just give averages.

"Averaging stamps out diversity, reducing anything to its simplest terms.
In so doing, we run the risk of oversimplifying, of forgetting the variations around the average" - Kaiser Fung

To determine your optimal level of care you'll need to delve into your physical therapy evidence base (or pay to have it done for you). It's not that hard, in fact, the hardest part is just getting started.

This article discusses some of the predictors of function for shoulder patients, depending on how you assess outcome.

Read...
Prognosis in Soft Tissue Disorders of the Shoulder: Predicting Both Change in Disability and Level of Disability After Treatment

Nancy Garland, physical therapy advocate, wins 20th District in Ohio

Democrat Nancy Garland won her hotly contested seat Tuesday November 2nd for her second term in Ohio's 20th legislative district.



At a recent national meeting of physical therapists Nancy said that her race was being watched closely by national leaders on both sides of the political spectrum. Ohio is an important state for both parties since it will figure prominently in the 2012 presidential campaign.

According to the Columbus Dispatch...

"House Democrats tried to use a 2-1 money advantage to hold back the GOP wave.
The national party and a handful of independent groups also pumped millions into legislative races on behalf of Democrats."

I met Nancy Garland, JD at the APTA State Government Affairs meeting in Portland, Oregon from September 26th-28th, 2010.

Nancy presented her ideas on running for public office in a very practical, "here's-how-it-affects-you" manner for physical therapists who might consider running for public office.

The rehabilitation community needs people like Nancy, former CEO of the Ohio state chapter, in public office. Many other professions have their advocates in state legislatures: chiropractors, orthopedic surgeons, attorneys and land developers.

Physical therapists also need advocates in politics.  Nancy is not a physical therapist but, before becoming an Ohio state legislator in 2008, she ran her state physical therapists' association for seven years.

Nancy is also a clinical assistant professor at The Ohio State University School of Allied Medical Professions where she teaches Health Policy in the physical therapy doctoral program.

Nancy has passed many health care related bills while working as the State Representative for Ohio's 20th District. Furthermore, her actions in her first term improved opportunities for physical therapists and their patients:

• Fixed the educational funding system that was unconstitutional and have begun the educational reform needed to prepare Ohio students for the 21st century
• Expanded health care to more Ohio citizens
• Passed legislation to require insurance companies to cover treatment of Autism-Spectrum Disorders

Nancy is known as the "The Listening Legislator" and has held numerous town hall meetings, coffees, and community meetings to hear the concerns of the citizens of the 20th District.

Nancy's statements on healthcare are consistent with physical therapists' goals and issues:

"I want to create an environment where citizens have access to primary care while also focusing on prevention and wellness."

Congratulations on your win, Nancy!

Frequently Asked Questions about Treatment Based Classification (TBC)

Can I substitute mobilization for thrust manipulation?

No.

High-velocity “thrust” movement has been shown to be an important component of the treatment in the lumbar manipulation decision rule. Treatment with lumbar mobilization was shown NOT to result in better outcomes (Hancock et al).

The same logic applies to manipulation for anterior knee pain although that rule is still in the derivation stage.

No direct comparison of mobilization vs. manipulation has been performed for thoracic manipulation. The thoracic manipulation rule has been subjected to a broad validation study that showed improved functional outcomes in the manipulation + exercise group over the exercise-only group.

Further, the thoracic manipulation rule was NOT shown to predict response to treatment better than subjects manipulated without the rule.

Therefore, the authors concluded that ALL patients with neck pain without red flags for pathology should be manipulated.

Are TBC groups mutually exclusive?

That is, are all members of the lumbar manipulation group also NOT in the lumbar stabilization group? Conceptually, exclusivity is important in designing treatment groups for study. However, clinical reality belies this notion.

Manipulation and stabilization appear to be non-compatible, even contradictory, approaches to an episode of spinal care. Anecdotal reports affirm that many patients, once managed acutely with manipulation, qualify for stabilization training in the long run.

Zimny acknowledges that strict categories actually lower the percentage of patients who can be classified at all.

Are TBC groups exhaustive?

Have researchers identified all possible patient groups?

There is an uncertain benefit in trying to classify EVERY possible group when the cost and effort of rule development outweigh the possible benefits.

Hart discusses the possibility of a prediction rule that might imply the necessity for modality use in a small, well-defined cohort of patients.

Childs describes “general conditioning” as perhaps the largest cohort of patients that would benefit from physical therapy intervention. With education and possibly amended state licensing laws a rule defining this group could be applied to pre-symptomatic patients for screening and risk assessment.

What conditions are appropriate for Treatment Based Classification (TBC)?

High-volume conditions with vague indications for treatment (eg: LBP) or no consensus on treatment (eg: neck pain) are candidates for the full, four levels of rule development.

Conditions for which there is general consensus on treatment (eg: ankle sprain) may not be appropriate for full-scale rule development.

Is TBC “cookbook” medicine?

To professionals trained in a culture of naturalistic and intuitive decision making an algorithmic approach where treatment decisions are supported by “likelihood ratios” may initially seem threatening.

But, TBC algorithms can be used initially for the “heavy lifting” in developing the Plan of Care with Frequency, Duration and Expected Outcome boilerplate outputs that allow physical therapists to concentrate their time and attention on face-to-face interaction with the patient rather than tedious, narrative notes.

Expert decision makers in many disparate fields use naturalistic decision making for their common tasks.

Likewise expert decision makers also use sophisticated tools, like TBC algorithms and decision rules, that speed up complex jobs.

“A tool is a trick I use twice.” – George Polya

McGee notes that the need to establish accurate pre-test probabilities, used extensively in epidemiologic testing, requires knowing many patient characteristics in far greater detail than is possible without sophisticated data collection tools and analysis.

Finally, the father of SOAP notes decries memory-based systems in medicine that hold doctors and physical therapists accountable for perfect recall and processing of medical information:

“We use probabilities in decision making in direct proportion to our ignorance…of the situation.” - Lawrence Weed, MD

How can TBC improve Medicare compliance?

1. TBC decision rules provide an evidence-based plan of care (frequency, duration and expected outcome) within the first 15 minutes of the evaluation.
2. TBC allows physical therapists to concentrate on the value exchange - the face-to-face interaction that typifies a physical therapist interaction.
3. When you are in your office, reading a chart, writing a note or pecking at your computer you are NOT giving value to the patient.
4. TBC can establish medical necessity for physical therapy.
5. Since most TBC decision rules use self-report questionnaires as outcome measures they can create a culture of outcomes measurement in your physical therapist workforce.
6. TBC requires a probabilistic mindset – a way of thinking that accounts for risk factors, baseline factors and outcomes that will come to define skilled physical therapy decision making.
7. TBC is a tool that creates autonomy in your physical therapist workforce. When you can describe your patient characteristics that predict outcome better than the referring physician can describe you become a resource for that physician.

An Interview with Dr. Stuart McGill

Hi, my name is Sasha Sibree, PT.

First, I would like to thank Tim Richardson, PT who has kindly allowed me to do a guest post on his blog.

I recently had the opportunity to interview Dr. Stuart McGill about his work with rehabilitation exercises for the lumbar spine.

Here are some excerpts from the interview...

***Begin Transcript***

PhysicalTherapyContinuingEducation.Org: "Well, we know from your work that Transverse Abdominis (TrA) is not the whole answer to spinal stabilization, but isn't it beneficial to still prescribe Transverse Abdominis exercises to make sure that muscle is working well?"

Dr. Stuart McGill: "Well, I think I've just caught you in a nice little clinical controversy."

PhysicalTherapyContinuingEducation.Org: "Okay."

Dr. Stuart McGill: "Show me one study that says the Transverse Abdominis is not working."

PhysicalTherapyContinuingEducation.Org: "Well, Dr. Paul Hodges' work.
Plus I recall there was an article in JOSPT recently about Australian Football players."

Dr. Stuart McGill: "Okay.
Well, if you think Hodges' work, let's stay with that.

He's never shown that the Transverse Abdominis is not working."

PhysicalTherapyContinuingEducation.Org: "I stand corrected.
The TrA doesn't fire correctly."

Dr. Stuart McGill: "He's shown that in a very, very tightly controlled experiment of people standing - and they sort of have to relax in a very special way - and they jerk one arm into flexion.

That's the only time that he's found, in a few back pain patients, about a 30 millisecond delay in activation.

It'’s not that the TrA isn't working. It's slightly delayed in onset.

A lot of people have tried to replicate that experiment.

They haven't got as much press as Dr. Hodges has and they haven't found that pattern.

They've found delays in other muscles, absolutely, but when they sub-categorize the various flavors of back pain they've been able to show that certain back pain patients have no delays at all.

Some have much bigger delays in Erector Spinae.

There have been all sorts of studies that show Latissimus Dorsi has huge delays in rowers, for example, with back disorders.

Anyway, my point in this, it's only in this very contrived arm raise task.

You show me one other task where Transverse isn't working?

It's a myth."

***End of Transcript***

I thoroughly enjoyed speaking with Dr. McGill during this thought provoking 36 minute interview. I hope you enjoyed this excerpt.

I invite you to visit my site to listen to or download the entire interview.

My site is called Physical Therapy Continuing Education.Org.

Basically I found a way to combine my love of learning and being an internet geek. I hope you take advantage of the whole series of free interviews I am doing with some of the top rehab experts in our field.

Thank you,
Sasha Sibree, PT
PhysicalTherapyContinuingEducation.Org

Free Falls Risk Reduction Toolkit for Physical Therapists and Patients

Get the Falling LinKS Toolkit from the Wichita State University Regional Institute of Aging

This is a very user-friendly document with clinical and personal vignettes that "paint-the-picture" for patients, payers and professionals who may not be fully aware for the risks and the resources available to help prevent falls.

The toolkit hits the "big drivers":

• Overmedication
• Vision deficits
• Inadequate physical activity
• Environmental risks in the home

The toolkit lets patient assess their own risk by checking off boxes and scoring the results simply by accumulating the total - the more "yes" answers the higher your risk.

There is an exercise section with pictures of safe techniques that are functionally-oriented (no leg raises!) with a balance component.

There are checklists to create an exercise plan, a vision plan, a medication plan and a safe home environment plan.

Implementing all of these plans will take a commitment from the whole family, the physician and the physical therapist

I have sent my dad a copy and I will help him implement these steps when we visit at Christmas.

Physical Therapists: The LAST, Best Choice!

Many of my physical therapist friends say that Physical Therapy is your FIRST, best choice for consumers - before drugs, before surgeries, before scary, invasive, expensive diagnostic imaging like MRI and CAT scan.

Physical therapists can treat and prevent painful disability - this is the kind of problem that, unlike heart attacks, strokes and cancer - may NOT kill you but may leave you paralyzed, immobile or wheelchair bound.

You may have difficulty with simple things in life:

• Getting up out of a chair
• Playing with your grandkids
• Climbing stairs

But, I want to show you why physical therapy may also be your LAST, best choice!

From the journal Health Affairs (Sept 2005):

This rather hairy image shows that spending for LEAST disabled persons is rising almost as rapidly as for the MOST disabled.

"Among community-dwelling elderly, spending growth among the least disabled grew more quickly than among the most disabled, which offsets some of the cost savings associated with declining disability rates."

The good news is that disability rates have been falling, relative to population growth, for several years:

People are living longer, in less pain and less disability.  Costs, for this cohort, are not costs - they are an investment.  We are investing in better quality of life for America's seniors...

Outpatient Therapy Task Force 2

Notice that the 85-89 year old people are the highest users of therapy?

They use, on average, $857 in outpatient therapy per year - higher than any other group of Medicare beneficiary.

Can we attribute the declines in disability to the higher utilization of therapy services? Do survivors tend to use therapy services disproportionately?

Currently, therapy services are "defaulted" when physicians can't find a surgical lesion to cut. Or, when medical marketing fails to convince seniors that yet another injection, drug or operation will help them feel better

If therapy services can be shown to reduce disability in America's oldest cohort then American's may want to continue spending in this area by targeting therapy dollars to the group most able to benefit - America's oldest citizens.

Physical therapy may be their last, best choice.

Free Help Guide for Physical Therapists

Get this free help guide to biostatistics for Physical Therapists from MedPageToday.com

The guide contains familiar terms to physical therapists such as "reliability", "sensitivity" and "specificity" but it also goes into new and important concepts such as "odds ratio", "likelihood ratio" and "relative risk".

As Guy G. Simoneau and Stephen C. Allison comment in the October 2010 Journal of Orthopedic and Sports Physical Therapy:

"...more attention is needed to improve our understanding of the accuracy of commonly used diagnostic tests."

Not all tests are created equal - some commonly used physical therapy tests are nearly worthless.

And, many medical screening tests are sufficiently predictive, simple to use and within the scope of practice of physical therapists. This guide will help you understand the tools and concepts needed to evaluate the tests.

I hope you download and enjoy this free help guide from MedPageToday.com.

Take Home Message from APTA State Government Affairs

I recently attended the American Physical Therapy Association(APTA) State Government Affairs meeting in Portland, Oregon as one of the Florida delegates. This meeting is intended to create advocates for the physical therapy profession by creating awareness of the common struggles we all face at the state level.

State level advocate physical therapists keep politics local and create national awareness of the inherent value physical therapy brings to medicine and to society. A local "grassroots" effort can complement the Federal advocacy by APTA in Washington DC as well as the more expensive and long-range public relations and "branding" campaigns initiated by our leaders.

State of the States – many issues are dealt with at the state level but have national commonalities from which we can all learn. This was an inspiring subject because of the many “success stories” told by our peers in other states.

• Dry Needling
• Dry needling is NOT mentioned in the Guide to PT Practice. Many therapists in Europe and the USA are learning dry needling techniques.

• Infringement
• massage therapists want to practice joint manipulation.
• Physical Therapists successfully partnered with chiropractors in Virginia to prevent advertising the term “physical therapy” without a PT present.
• Medicaid
• PT is an optional service for adults but will be required for children under Health Care Reform.
  
• Direct Access
  
• PTs can “diagnose” and should avoid equivocating between a “physicians’ diagnosis” and a “physical therapists' diagnosis”.
  
• Excessive Co-Payment Barriers
• New York is fighting a tough battle with $50 co-pays for plans with a $50 PT benefit.
• New York has crafted their own legislation that would mandate co-pays no more than 20% of the benefit amount.
• Vetoed by the Governor as a tradeoff for increased Work Comp fee schedule.
• Any states seeking such legislation need to ensure that PT is a “mandated benefit” otherwise insurance companies will allow the co-pay but drop the benefit.
  
• Federation of State Boards of PT
• Seeking a recertification process to protect public safety.
• APTA is not disagreeing with FSBPT.
• Consistent with physician licensing, but…
• …is there a demonstrated need (eg: evidence of harm from malpractice insurance carriers?)
• Many state boards are controlled by physicians (not in Florida!)
• In states where the Board is controlled by physicians or agendas set by powerful administrators PTs need to develop a “culture of autonomy”.

Health Care Reform (HCR) – this is a “hot topic” made even hotter by the concise, hard-hitting analysis by Justin Moore, PT and two outside experts – quality “gurus” who were passionate about the next stages in HCR.

• the regulatory approach (influencing policymakers) is preferable to the legislative approach (eg: South Carolina and Washington state).
• Anti-POPTs legislation too expensive.
• HCR will unfold over the next 5-6 years, allowing PTs time to influence policymakers.
• Cost arguments will dominate the conversationDr.

"Quality Gurus"

Edward Keenan, PhD from The Foundation for Medical Excellence spoke on Achieving Health Care Reform Require Transformation Not Reform

• HCR grants access, NOT quality
• 15-minute visits (encoded in CPT) prevents quality and encourages “silos”.
• “Health Care” may contribute only 10% to “Health” but education may contribute 40-50% to “Health”. 
•  Lifestyle, genetics and culture also contribute to “Health”.

Jack Friedman, CEO of Providence Health Plan spoke on The Impact of Health Care Reform on Health Benefit Design

• HCR will create “tiers” of healthcare;
• primary care is 1st tier,
• PT may be 2nd tier 
• instrumented spinal fusions should be 3rd tier.
• Small practices will have to integrate with Accountable Care Organizations (ACOs) to participate in bundled episodes of care.
• PT’s need to demonstrate “Value” to the ACO.

Starke Anti Self-Referral Laws

• Starke affect Medicare patients only but needs revision:
• Sharing of health IT (EMR) is currently prohibited among providers.
• Integrated Accountable Care Organizations (ACOs) may be prohibited under Starke.
• PT is a professional service, NOT an ancillary service (Hogan/Hartz whitepaper)
• PT is more akin to radiation oncology than any other service in its scope, usage patterns and timing.

AMA Scope of Practice Guidelines

• The AMA is attempting to write the PT scope of practice ‘for’ us.
• Physicians have an unlimited scope of practice.
• The APTA rejected the AMA's premise that the AMA can define the PT scope of practice.
• Physicians define everybody else (including PTs) as “limited license practitioners”
• APTA believes that physical therapists should define our scope of practice through updated versions of the Guide to PT Practice.

Action Plan for the Future: In the private practice setting innovation may become more rewarding.  Traditionally, the words innovation and Medicare have seldom been used together.

How Can Private Practice Physical Therapists Innovate?

1. Choose the lowest cost means of communicating with your patient - (e-mail)
2. Assume all the performance risk of the outcome - what can you do to improve the outcome that you have not traditionally done? For outpatient physical therapists, this might mean home visits to visualize the patients' home environment assessing for specific risks, eg: in older patients throw rugs, pets and stairs may increase falls risk. As the therapist you can modify these risks to prevent future resource use.
3. Is the small private practice the way to go? ACO's will want to contract with ONE therapy provider. Would a Independent Practice Association (IPA) of several small PTPP practices enable better negotiation with the ACO? What about a merger? A sale?
4. Stay tuned - there is no fixed definition of an ACO.  Some will be hospital-based and some will bebased on large physician practices .
   

"All In" for Physical Therapy!

Armin Lodges, PT has created the Florida Physical Therapists in Private Practice (FLPTPP) group to organize and collaborate for physical therapists' future in Florida.

Armin has scheduled a meeting at his clinic in Tampa on November 3rd to discuss strategy.

FLPTPP - come find out! on Prezi

Armin has created these two "Prezi Slideshows" to get out the message. All interested Florida PTs should contact Armin at armin@restoretherapies.com or call 1.888.675.4331

Unifying Florida PTs in Private Practice on Prezi

Small practice therapists are at the mercy of large insurance companies and large hospitals and the recent healthcare reforms have further skewed the environment towards large, "vertically integrated" providers.

Let's all join Armin and fight for our livelihoods and for what we believe to be a better vision of healthcare for Americans.

On the benefits of Seeing a Physiatrist

Not many people are familiar with the term “physiatrist”; while they know what a physical therapist does and they’re no strangers to doctors, they are not aware that a physiatrist is a physician and a physical therapist rolled into one.

Simply put, a physiatrist is the person who cares for people with physical impairments and disabilities and pain caused by acute and chronic conditions. They’re medical doctors who specialize in restoring optimal function to injured and damaged muscles, bones, tissues and the nervous system.

If you suffer from acute and chronic diseases that affect the quality of your life, cause you severe and debilitating pain, and prevent you from moving well or using your limbs and joints optimally, here’s why you would benefit from seeing a physiatrist:

• You eliminate the need for surgery: some doctors may tell you that conditions like a slipped or prolapsed disc could require that you undergo a painful and stressful surgery – you not only have to go through the complicated procedure but also spend a lot of time in bed recuperating from the operating.
  
• However, when you consult a physiatrist, you may find that there’s no need for a corrective surgery and that exercises and physical therapy alone are enough to improve the quality of your life, enable you to move freely, and eliminate the constant pain.
  
  
• Treatment is customized for your condition: In physiatry, there is no one-size-fits-all treatment – your doctor is qualified to examine you thoroughly, analyze your condition, and suggest a holistic treatment that is designed to eliminate pain and enable fluid movement. Every patient is treated differently, based on their condition (chronic or temporary), pain level, ability to move, and difficulty in leading a normal life.
  
  
• You boost the quality of your life: Even if your condition is not completely curable, your physiatrist will suggest ways to improve the quality of your life through moving aids and implements, teach you exercises that prevent loss of muscle mass and keep you active and flexible even though your mobility is limited, and continue to monitor your condition and change treatment based on your response and improvement.
  

Unlike chiropractors and massage therapists, a physiatrist is a fully qualified doctor with over 8 years of academic study and many years of experience.

A physiatrist can help you treat mobility issues and pain caused by various conditions including strokes, spinal cord injuries, sports-related injuries, multiple sclerosis and other neuromuscular disorders, cancer, brain injuries caused by trauma, lung conditions, back, knee and shoulder problems and other musculoskeletal disorders, accidental injuries, amputations, arthritis and other debilitating conditions, and other movement-related disorders that affect the quality of your life.

It takes patience and perseverance to improve the quality of your life and eliminate pain, so stick with your therapy, and see how much you stand to gain from physiatry.

By-line: This guest post is contributed by Paul Hench, he writes on the topic of masters in public health. He welcomes your comments at his email: paul.23hench@gmail.com

Paul decided to start a website to help students find online programs in Public Health. So he listed all the schools and Universities offering public health degree programs. He created the site MastersInPublicHealth.net and now he is providing his full efforts to bring this to the front.

He is trying to become the first unbiased resource that students can use to research every single accredited Public Health program offered by a college or university in the US.

Paul has a passion for writing articles on Health, Education and masters in public health programs. He and his wife Mary resides in Texas, USA and Mary is now continuing her online Masters in Public Health.

The Treatment Trap

Author Rosemary Gibson, MD details the ills of the US healthcare system in her new book The Treatment Trap:



She spoke July 26th, 2010 at St. Peter's Healthcare System which was aired on C-Span 2 on September 5th, 2010 at 10:30am EST.

Here are some of her discussion points from her book:

• Those who speak out against medical over-treatment risk being labelled, in this current political climate, as "rationing". Dr. Gibson speaks of over-treatment from a quality perspective, however, not from a financial perspective.
• High-technology may not be the solution. Even Electronic Medical Records (EMR), the "savior" of modern healthcare, may not always deliver what it promises.
• Obama's failure to implement tort reform with healthcare reform saddles doctors with a "fear factor" which drives wasteful medical spending.
• The "fear factor" produces a "wall of silence" among doctors that perpetuate medical errors and prevents learning.
• Palliative care produces better outcomes than expensive, high-risk, end-of-life care that often leaves the patient worse off.

This book is targeted to patients as well as non-policymaking practitioners. Dr Gibson presents "Twenty Ways to Protect Yourself" as practical advice for patients trying to negotiate American healthcare.

Perhaps one of her statements made in front of the TV camera provided me with the most compelling reason to order this book:

"Health insurance used to be about giving patients access to providers.
Now, it's about giving providers access to patients".

Empathy and Physical Therapy

Author and advisor to world leaders Jeremy Rifkin talks about Mirror Neurons (and more) that may explain how humans relate to each other.

His presentation begs the question:

If babies cry because other babies are crying, not because they are hurting or hungry, and their behavior is due to their "mirror neurons" that what implication does that have for our chronic pain patients in physical therapy.

How much chronic pain behavior is learned behavior, not mechanical?



Foe example, if I am treating a chronic pain patient who is anxious and depressed and I respond to him with empathy, optimism and encouragement will his mirror neurons cause his mental status to improve?

Can we measure his improvement clinically (without an MRI)?

Dr. Rifkin goes on to draw many other conclusions from his data on mirror neurons and the video is worth watching for his compelling arguments, scientific data and the interesting animations.

Is the United States Government Biased Against Private Practice Physical Therapists?

I've thought about this subject for several months - ever since March 2010 when MedPAC delivered its annual Report to the Congress: Medicare Payment Policy.

Now comes this recent article from The Annals of Internal Medicine, picked up on the Evidence in Motion blog, that verifies the implications of the MedPAC report and my suspicions.

The report was black and white evidence that our government is biased against small healthcare providers - where 70% of American healthcare takes place!

Medicare "guess-timates" on adjustments to the Physician Fee Schedule based on access to capital markets for selected healthcare sectors.

"Substantial increases in the number of providers may suggest that payments are more than adequate and could raise concerns about the value of the services being furnished...

The volume of services can be an indirect indicator of beneficiary access to services...

Volume is also an indicator of payment adequacy; an increase in volume beyond that expected for the increase in the number of beneficiaries could suggest that Medicare’s payment rates are too high."

Providers’ access to capital

"Access to capital is necessary for providers to maintain and modernize their facilities and capabilities for patient care.
Widespread inability to access capital throughout a sector might in part reflect on the adequacy of Medicare payments (or, in some cases, even on the expectation of changes in the adequacy of Medicare payments).
However, access to capital may not be a useful indicator of the adequacy of Medicare payments when the sector has little need for large capital investments, when providers derive most of their payments from other payers or other lines of business, or when conditions in the credit markets are extreme."

Guess what? Small clinics like mine and yours DON'T have access to the capital markets! These days we may not even have access to bank lines-of-credit anymore!

The MedPAC report implies that only large firms with scale economies, access to capital markets and administrative staff that can maximize revenue and compliance will succeed in the future.

The Annals article, titled The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges was written by physicians with close ties to the present administration. Their opinion echoed the MedPAC report:

"The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.
The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience."

No rebuttal was printed by the Annals editors but many online readers voiced vigorous opposition to the politically positive tone of the Annals article.

Physical Therapists and the Multiple Procedures Payment Reduction Policy (MPPR)

The recent, proposed Multiple Procedure Payment Reduction (MPPR), is just the end result of policy discussions at high levels that those of us in private practice can only react to - we usually don't get a voice in these decisions.

Hopefully, many of us wrote letters to the head of the Centers for Medicare Services, Dr. Donald Berwick, pointing out that the projected 13% revenue "savings" will be disasterous for private practice physical therapists and their patients.

Here is a copy of the letter I sent.  The comment period closed August 24th and we'll learn the final adjudication November 1, 2010.

Take Home Message

I don't think the future of physical therapy belongs just to large firms - private practice physical therapists can still effectively compete.

The Annals authors, however, do not believe managing future change is possible in small practices:

"Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."

They appear to have reached the conclusion already that small businesses in medicine and physical therapy will go the way of the dinosaur.

In order to prevent our own extinction we will need to gain control of the one thing that we have that the government wants - our patient data. We need to control not just outcomes data but also baseline data on patient characteristics that affect outcome. Also, we need to show that our decisions on patient care are BETTER than physicians decisions.

Why are physicians referring patients to us? We should be referring patients to them! We should be the point of entry!

But, to gain control of our data we will need better systems for managing data.  Not just Electronic Medical Records (EMR). And not just Clinical Decision Support (CDS) systems, either.

We'll need a marriage of EMR and CDS that will improvement the process of care - as delivered by physical therapists.  We'll need to show that ONE care process in particular: care delivered hands-on by physical therapists DOES lead to better outcomes.

While outcomes are difficult to measure, process measures are much easier. I have not been especially happy with many burdensome process measures in physical therapy but hands-on care is a "no-brainer".

This new study in the August 2010 Physical Therapy Journal is just the second published article showing that PT process measures improve patient outcomes.

What to Do?

Ask your EMR vendor about integrated decision support - what are you doing with your data?  If you don't have an EMR you can still use pen-and-paper decision support tools - usually paper templates - that can be stored in the patients' chart.

These templates can be set up to predict the duration, frequency, total cost and expected outcome. Baseline co-factors can alert us ahead of time to those patients at risk for "failing" in physical therapy - these are the "outliers" that Medicare so desperately wants to identify.

Some "outliers" will need more therapy, some will need referral to psychological screening and some will need surgery.

I hope we can convince the Congress soon that the most efficient setting for physical therapists to serve Americans in this way is often the small, outpatient physical therapy office.