"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 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.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
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