"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

Saturday, February 27, 2010

Anthem BCBS Profiteering and "Irresponsible Behavior"

Sparks flew, feelings were hurt and somebody got their noses rubbed in it in this riveting, nail-biting exchange between the House Commerce Committee on Oversight and Anthem/BCBS CEO Angela Braly and Executive VP Cynthia Miller.

Anthem BCBS is being called on the carpet for their 39% rate hike on the individual California health insurance market.

Some notable moments:

Anthem BCBS posted a "reasonable profit" in 2009 of $2.385 billion

Unadjusted Q4 2009 income of $2.7 billion - before the sale of a pharmacy benefits management company was excluded as a one-time gain.

Ms. Braly's 2009 take-home? $1.1 million salary, $8.5 million in stock options and $730,000 in incentive bonuses.

She made over $10,000,000 in a year where 25,000 ADDITIONAL Californians dropped their health insurance because they were unable to pay for it!

See the video:

Also see these highlights:
  • Rep. Bart Stupak (D-Michigan) spanks the Anthem CEO for the practice of "recission" or as he calls it "purging sick people".
  • Rep. Henry Waxman (D-California) pins Angela Braley's ears back for spending $3 million on meetings at 'a lavish resort in Scottsdale, Arizona'.
  • Rep. Jan Schakowsky (D-Illinois), in perhaps the most passionate exchange, demands Angela Braly's salary data (see above).
Take home message to Anthem Blue Cross/Blue Shield:

When the US House of Representatives calls you to explain your profiteering and irresponsible behavior that harms Americans try to present yourself in a humble manner.

Don't lecture the US Congress.

Don't blame the healthcare consumer for being 'unsophisticated'.

Don't blame doctors and hospitals for rising rate increases.

Don't keep getting rich off of sick and dying Americans.

Thursday, February 25, 2010

RACs refer two Rehab Providers for Fraud

A new report by the Office of the Inspector General reveals during the Recovery Audit Contractor Demonstration period from March 2005 to March 2008 in Florida, California and New York that two rehabilitation service providers were referred to the Centers for Medicare and Medicaid Services (CMS) for possible fraud.

The RACs are not responsible for reviewing claims for fraudulent activity only for identifying improper payments.
The two referrals involved rehabilitation service providers and both involved suspected alterations of medical records after the services were rendered.

According to the RAC referral letters sent to CMS, the RAC had no contact with the providers in reference to the allegations and continued to complete its complex and/or automated, postpayment review of the providers.

If CMS had determined that the referrals were potentially fraudulent, the RAC should have ceased its review of these claims.
More Medicare audit resources are found here.

Wednesday, February 17, 2010

The Knee is a Dumb Joint...

The knee is a dumb joint...

At least according to the evidence presented by Dr. Scott Greenberg, DPT, BSC, CPed, CSCS and his peers of the University of Florida Sports Performance Center.

Scott Greenberg DPTDr. Greenberg was one of the hosts of the world-class faculty at the Running Medicine Clinic at the Orthopedics and Sports Medicine Clinic in Gainesville, Florida on February 11th-12th, 2010.

Dr. Greenberg presented evidence that described the knee as an often painful, weak link between the ankle and the hip.

The course was presented by Course Director Kevin Vincent, MD, PhD and featured guest speaker Francis G. O'Connor, MD, MPH, COL, MC, USA.

Dr. O'Conner is the author of The Textbook of Running Medicine and the Medical Director of the Marine Corps Marathon. Dr. O'Conner also happens to be active duty Marines and just finished a tour of duty in the Middle East, caring for US Navy SEALS.

The UF running conference is an annual occurrence timed to coincide with the Five Points of Life Gainesville Marathon.

The course content was largely consistent with a surge of evidence arguing that knee pathology is often driven by hip and ankle dysfunction. Some of the most recent evidence was published, coincidently, in the February Journal of Orthopedic and Sports Physical Therapy.

Christopher Powers' PT, PhD Clinical Commentary article presents compelling data on hip biomechanics that summarizes the kinematic and kinetic data to date and may change common practice patterns for knee rehab.

View Dr. Powers slideshow on knee and hip kinematics here (JOSPT log-in required).

patella kinematicsTwo ways to move the knee

Non-weightbearing: This image is an example of the dysfunctional lateral movement of the patella in non-weightbearing (like on a knee extension machine). In this image the mobile patella is pulled laterally on a stable femur.

Weightbearing: Dr. Powers' article also describes lateral patella movement in weightbearing (like a single leg squat) where the mobile femur internally rotates under the stabilized patella.

Excessive hip internal rotation and adduction seem to be some of the most persuasive drivers behind common, high-volume conditions seen by physical therapists involving the knee.

Interestingly, Dr. Powers article presents some conflicting data: isometric assessment of hip muscle force producing capacity (strength) correlates poorly with the expected data on hip kinematics. One possible source for this conflict is the high rate of measurement error with isometric muscle testing (eg: MMT).

If hip kinematics are the main drivers behind anterior knee pain then that explains the poor outcomes of arthroscopic knee surgery in two randomized , controlled trials from 2008 and 2002.

We've known for ten years (at least) the value of non-operative treatments to the hip, knee and ankle for primary knee pain.

Runners are just one of the many niche groups that benefit from the 'functional' physical therapy diagnosis.

The knee is a dumb joint but a smart example of how physical therapist diagnosis can improve outcomes and decrease health care costs.

Tuesday, February 16, 2010

PT Managers can now use TBC to set Long Term Goals

Physical therapy managers are always trying to find ways to:
  • reduce paperwork (and spend more face-time with your patient)
  • speed up productivity (and make more money)
  • lower the costs of care (and make more money)
  • see more patients (and keep your job)
  • get the patients better (and get good outcomes)
  • get the right stuff in the chart (for Medicare compliance)
Treatment based classification (TBC) uses a parsimonious (brief) set of tests to identify who will get better with which treatment.

For example, the Cervical Traction classification uses these tests (predictor variables) to identify patients who will respond well to cervical traction:
  • Peripheralization with the C4-7 mobility test
  • Age> 55
  • Positive shoulder abduction test
  • Positive cervical distraction test
  • Positive Median nerve tension test A
The modifiable findings are in bold. Age is not modifiable. The others may change as a result of your care. The test results are expressed as percentages:
  • The baseline chance of being in the cervical traction group is 44%.

  • Three-of-five (3/5) positive tests implies a 79.2% chance of success with cervical traction.

  • Four-of-five (4/5) positive tests implies a 94.8% chance of success with cervical traction.

  • Five-of-five (5/5) positive tests implies a 100% chance of success with cervical traction.
What if we set up our goal in quantitative terms? Reduce the risk of needing cervical traction to the baseline level of 44%.

The long term goal would be written like this:
"Improve cervical traction risk classification from 94.8% to 44% in four weeks"
The goal is objective, quantifiable and easy to implement.

If you use TBC Templates, available here, you can check your patient's status with simple check boxes weekly.

Attach the template to your electronic documentation and eliminate lengthy, narrative descriptions of 'skilled therapy'.

Treatment based classification holds the promise of better physical therapy outcomes at lower cost.

Now, you can use templated (electronic or paper) TBC checklists to reduce your paperwork and speed up your productivity, too.

Saturday, February 13, 2010

Physical Therapy Process Beats Outcome

The current tally of officially recognized 'process' vs. 'outcome' measures in health care from the National Quality Measures Clearinghouse (NQMC) favors 'Process' over 'Outcome' by 997 to 368.

If physical therapists define quality by 'how' we deliver care over 'how much better' our patients get - then our patients are in trouble.

nqmc screenshot
click image to view larger size

Why is this important?

Outcomes-based care is where the United States health care system is going.

Physical therapists can be leaders in this transition. The adoption of outcome measurement by our profession will the the 'speedometer' by which that transition is gauged and will ultimately decide the winner.

Unfortunately, the adoption of evidence-based outcomes tools is slowed by the burden of 'process-based' measures in physical therapists' clinics.

A partial list of some 'un-official' process measures in physical therapy:
  • Therapy cap exceptions process (-kx modifier)
  • ‘Skilled therapy’
  • 10th visit progress note
  • 90-day certification of the plan of care
  • Physician signature of the plan of care
  • AMA definition of physical therapy practice (via 15-min CPT codes)
  • Automatic CPT coding edits
  • 1-on-1 procedure codes
  • time-in & time-out
  • Medicare Minimal Documentation Requirements
  • ‘8-min. rule’
  • Discharge from physical therapy
These process measures, that dictate 'how' physical therapy is provided, all but eliminate the time, energy and money required for investments in true quality.

Where does all the time and money go?

Physical therapists nationwide (~177,000), especially those working in outpatient therapy clinics (~65,000) are burdened by excessive documentation of uncertain value - the primary reason for documentation seems to be to protect ourselves from Medicare audits.

Witness this description of the 'process-oriented' note that is supposed to accompany the billing of one, single code for Therapeutic Exercise (CPT 97110):
"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait"
This description was made by Medicare auditor and former private practice physical therapist Steve Levine, DPT in a February 3rd, 2010 webinar called "Will Your Documentation Trigger an Audit?"

Dr. Levine's recommendation to over 400 members of the webinar cast a chilling pall over the prospects for improvements in the rate of physical therapists' adoption of outcome measures in the short-run.

The very last question in the webinar was posed by a physical therapist clearly non-plussed by the idea that every 1-on-1 procedure code need to be accompanied by this lengthy, narrative description.

Dr. Levine did not relent, implying that we need to spend as much time writing justifications for our care as we spend providing our care.

Some Process Measures are not statutorily based

Keep in mind that Dr. Levine's recommendations are just that - recommendations.

The Medicare Minimal Documentation requirements do not specifically require this level of narrative:
"...a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task...

Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition...

...Documentation should establish through objective measurements that the patient is making progress toward goals...

...It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus."
(Transmittal 88, page 25-26)
I could have written Dr. Levine's narrative description in 1992 - the year I graduated from PT school. Why should I write it now, in 2010?

Are we all crooks?

Is physical therapy still practiced the way they taught me then? I don't think so - today we have evidence-based physical therapy (the term was only invented in 1991).

Surely the profession could come to a consensus on what constitutes 'skilled physical therapy' that incorporated the best, up-to-date evidence on screening for pathology, treatment based classification and interventions supported by grade 'A' or 'B' trials rather than case studies or anecdote.

Right now we are abdicating our profession to self-serving, ex-clinicians with out-of-date treatment paradigms.

Why couldn't Federally mandated evidence-based outcome measures supercede process-based time-wasters? Let's bring Medicare audits (and Medicare auditors) into the 21st century.

Let's reverse the score: 997 to 368 Outcomes over Process.

Monday, February 8, 2010

Physical Therapy Students Take on Direct Access

Samantha SooHoo, president of the Pre-Physical Therapy/Occupational Therapy club at the University of California, San Diego is energizing the discussion on direct access to physical therapy services.Samantha SooHoo, physical therapist student

If anyone would like to provide another answer to Samantha's questions please reply in the comments section below.

Here are Samantha's questions and my responses:

1. Tim, In your opinion, how would direct access to physical therapy be beneficial for the US Health Care System as a whole?

How would it benefit patients, physicians and therapists?

Direct access to physical therapists has the potential to lower costs: consider a typical course of treatment for simple lower back pain.
  1. patient has initial episode that fails to resolve within two weeks

  2. patient sees primary care MD and receives NSAIDs and a follow-up in two weeks

  3. patient follows-up and is distressed - medical decisions may be made based on pain severity rather than physical findings - in this case a referral for an MRI and a neurosurgical consult is made (2 weeks)

  4. MRI is negative and the neurosurgeon refers to PT (2 weeks)

  5. PT sees patient after 2 months, 3 physician visits and an expensive imaging scan.
Could this have been handled better? I think so - Samantha has touched on how we can do better in her follow-up questions.

2. What implications would direct access have for practicing physical therapists right now? Would there be additional training or continuing education required?

Routine use of medical screening tests for suspected pathology would need to become part of the standard of care for outpatient physical therapy patients.

Unfortunately, I do not see 100% of my PT/PTA employees performing medical/pathology screening. Where I can, I train my staff but more needs to be done.

I have hired 2 DPT's in the last year and neither one of them demonstrated in their notes signs of routine screening for pathology, clinical prediction rules or other use of evidence-based practice.

These practice patterns vary individually and across settings as I know physical therapists in Skilled Nursing Facilities (SNFs) that do routinely screen their patients.

Physical therapists are undergoing a cultural shift as we transition to a doctoring profession. Again, this isn't just about training new techniques but an attitude that we, not just the physician, are ultimately responsible for the welfare of our patients.

3. What aspect of physical therapy field needs improvement as it heads towards the direction of Direct Access?

Education does not seem to be the answer - if more education were the key my DPT employees would routinely exceed the performance of my non-DPT employees but that is not the case.

I find the difference is attitude - some people are just more willing to change their practice style when presented with evidence that the old way is less effective. What needs to change is the uncritical acceptance of many of the 'techniques' taught to us in physical therapy school.

Skepticism is important.

Don't worry, this problem afflicts medical doctors as well - unwarranted practice variation and idiosyncratic local 'standards of care' often have more to do with where you went to school than with the current state of the evidence.

4. Opponents of direct access argue that physical therapists may overlook serious medical conditions because they may not be able to refer a patient directly for diagnostic testing and are not trained to make medical diagnoses.

Tim, What is your response to this claim?

To continue the example from above: (LBP) expensive, sensitive imaging tests are often used to confirm that the patient is a surgical candidate rather than to rule out suspected occult pathology.

Physical therapists can employ evidence-based screening tests and findings from the history to test for suspected pathology. Patients who test positive on the screening tests can then be referred for diagnostic imaging.

The promise of clinical prediction rules is to distinguish the high-risk patients from the low-risk patients for these and other conditions:
  1. dizziness
  2. pneumonia
  3. acute chest pain
  4. DVT
  5. lower back pain
  6. Incidence of falling down
  7. and other common, high-cost drivers in health care.
Physical therapy is not a high cost driver in health care but it has a high growth rate - which means that scrutiny is applied to our highest volume codes (eg: 97110 Therapeutic Exercise et al).

Physical therapists use exercise in the prevention of disability and so the ability to make a medical diagnosis (eg: cervical radiculopathy) seems irrevelant.

Why not make a physical therapist's diagnosis oriented along a disablement model that focuses your decision making towards prevention and future risk reduction?

5. If direct access was indeed implemented, how would communication between physicians and physical therapists look differently than it does now?

Samantha, the fact is that I enjoy direct access (and payment) now in Florida and in 47 other states.

Patients will gain improved access to physical therapists with Medicare direct access - which is really what this discussion is about.

Again, physical therapists would be a primary entry point for patients and would take on responsibility for their patients welfare. Physicians who recognize these behaviors in physical therapists now tend to refer more patients because they see us as a resource.

Physicians owning physical therapy tend to drive up costs with an uncertain impact on outcomes - there is no evidence that they provide better care.


Samantha, PT has a lot to offer and the future looks very bright for patients and for society. Our profession has been on an exponential growth curve over the last 10-15 years from the standpoint of evidence and opportunities.

Don't let the current political morass (eg: the Massachusetts Massacre) get you down. PT may be better off without fee-for-service but there are too many vested interests preventing that from happening overnight.

Thanks for your contribution.

Samantha SooHoo is the president of president of the Pre-Physical Therapy/Occupational Therapy at the University of California San Diego. The club has about 60 members and their blog is available here. Samantha volunteers at Scripps Memorial Hospital in La Jolla in the outpatient rehabilitation services clinic.

Wednesday, February 3, 2010

The Florida Physical Therapy Association's 2010 Legislative Advocacy Academy

They say you should never watch sausage or our state's laws being made - you may enjoy the final product but you won't enjoy the legislative process.

This year physical therapists will challenge ourselves to update and modernize the physical therapist practice act (FS. 486).

The 2010 FPTA Advocacy Academy in Tallahassee put the lie to that old chestnut - when you get involved in grassroots advocacy for physical therapy you challenge yourself in a way that is scary and thrilling at the same time - I know because I did it from January 31st-February 1st, 2010.

I sat in a class of about 15 physical therapists and the FPTA Chief Executive Officer, Craig Crosby, while we listened to lobbyists, media consultants, staff lawyers, legislative assistants and other folks familiar with sausage, er... I mean laws, being made.

The agenda was as follows:
  • Ken Jacob, physical therapist and the legislative process

  • Sheila Nicholson, FPTA president and attorney on grassroots advocacy

  • Barry Monroe from the Florida Senate Health Care Staff

  • John Van Gieson, media consultant

  • Bob Rowe, physical therapist update on manipulation and chiropractic legislative intent.

  • Gene Adams and Martha Edenfield, FPTA lobbyists in Tallahassee

  • Lisa Weisman, House legislative aide in Tallahassee
The final result is an educated, motivated workforce that will help physical therapists introduce and pass a new practice act that will modernize our profession by, among other means:
  1. protecting the designator, DPT, as the Doctor of Physical Therapy.
  2. removing only specific designators (eg: practice acts 458, 460, et al) from referring to physical therapy.

    Anyone remember the issue with Advanced Registered Nurse Practitioners (ARNP)?

    They couldn't refer to PT because they weren't specifically designated. ARNP's receive their license under the nurse practice act (FS. 464) which is not specifically designated as being able to refer to PT. This issue will go away under the new practice act.
Direct Access is improved with this change although, for political reasons, the '21-day rule' will not be changed.

The new legislation can first be introduced on March 2nd, 2010 - the start of the 2010 legislative session in Tallahassee.

Physical therapists can help the process by calling your local, state legislator now, before March 2nd, and recommending support for an upcoming physical therapy bill.

A specific bill number will be available soon and updates are available at the FPTA website.

Tuesday, February 2, 2010

PT Assistants and Effectiveness of Treatment Outcomes

(Special thanks to Shannon Wills for guest hosting this post.)

The power of an effective and complete physical therapy program has to be experienced to be believed.

I should know what I’m talking about because I went from walking with crutches to playing racquetball at full strength in just 8 months, thanks to the intense physical therapy rehabilitation program I underwent.

Therapy helps you regain normal movement in your joints and other parts of your body after an accident or an injury; it helps you re-learn habits that are part of your daily routine, but which your brain has forgotten because of a stroke or other illness. Some programs can be done on your own, while others need the intervention of a qualified therapist or a physical therapist assistant (PTA).

Physical therapy is only as effective as the combination of the program that is designed for you, the therapist you’re working with, and most important of all, your efforts and dedication in adhering to the program without any excuse whatsoever.

So, if you’re allowed to choose between working with a physical therapist and a PTA, you’re definitely going to choose the former if you know a little about the hierarchy in this field. The reason is simple – why choose a nurse when the doctor is available?

PTAs are good at what they do no doubt, but while they can carry out treatments, they cannot reassess the patient on a daily basis, make diagnoses, or change the program of treatment based on the progress or prognosis of the patients. This could inhibit the recovery of some patients who would probably do better if their program was altered a little or if their routine was stepped up or down.

So when we look at the effectiveness of the outcomes of treatments that have been carried out by PTAs, we find that the quality of care decreases because the PTAs in charge are limited by their experience and the educational qualifications.

Predictors of Physical Therapy Clinic Performance in the Treatment of Patients With Low Back Pain Syndromes by Resnik, Liu, Mor and Hart provides evidence towards the same – a group of clinics that participated in the research found that in the treatment of patients with lower back pain syndromes, clinics that use PTAs sparingly provided superior quality of care.

While the outcome of this research does not mean that PTAs are not good at their jobs, it only goes to prove that a therapist has to be involved in the treatment at all stages, especially during the initial period of rehabilitation when it is easy to gauge the effectiveness of the therapy program and how the patient responds to it.

This article is written by Shannon Wills, who writes on the topic of Physical Therapy Assistant Schools .

Make your comments to this blog or e-mail Shannnon directly at shannonwills23@gmail.com .

Free Tutorial

Get free stuff at BulletproofPT.com

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.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.