Physical Therapists Meet at the Beach

Special thanks to Blaire Burton, DPT for organizing the Florida West Central District spring meeting, Saturday, March 27th at America's #1 beach!



The meeting agenda promoted the update to the Florida Physical Therapy Practice Act (FS 486) during the 2010 legislative session.

The update is designed to do the following:


Some of the outstanding moments at the meeting were the following:

• A lucid and pointed rationale from Adele Carr, PT for why keeping statutory language affirming 'Physical Therapy Aides' in the practice act is a dangerous move for the profession.


• An even-handed narrative from Sheila Nicholson, PT, JD, FPTA President on how and why the practice act is being updated.


• Many, many passionate examples of members who care about their profession speaking up, voicing their ideas and trying to get involved.


• At least two private practice owners I spoke to telling me how ALL their marketing is now Direct-to-Consumer, instead of the physician.


• A lively fund-raising appeal for the FPTA Political Action Committee (PAC) that garnered several hundred dollars - we need to do more in this area since chiropractors and doctors still beat physical therapists 10-to-1 in donations.
  
  This year, our goal is $75,000 - about double last year's donations - and you can help us make it. Remember, patients can also be donors to the FPTA PAC - they want to help preserve their access to physical therapy, too!

These web links contain important, timely information for Florida physical therapists:

Florida PT PAC

The new, proposed PT practice act has been filed with the legislature: SB 2146.

Follow, in real-time, the process of SB 2146 as it makes its way through the legislative process.

What do YOU want to see in YOUR practice act?

Now's the time to speak up.

Is Health Care Reform Good for Private Practice Physical Therapists?

Here are three reasons why health care reform may be good for physical therapists in private practice (PTPP).

1. Medicare Advantage
2. Medicaid to Medicare
3. Tax credits to small businesses

Under the health care reform laws being passed and signed into law right now Medicare Advantage funding is being cut.

Medicare Advantage (MA) plans are managed care plans that replace traditional Medicare, at the beneficiaries option, by paying part or all of the monthly $98 premium. The MA plan saves money by limiting the health care providers in the network and cutting traditional Medicare reimbursement up to 50% to physical therapists.

In Florida, one plan pays a $70 per diem where traditional Medicare used to pay $125.

These for-profit health plan cost the Medicare program more than traditional Medicare. According to the Medicare Physicians' Advisory Committee 2010 Annual Report to Congress:

"MA payments per enrollee are projected to be 113 percent of comparable fee-for-service (FFS) spending for 2010."

In Florida alone, according to Republican Representative Vern Buchanan...

"Over $200 billion would be cut from the popular Medicare Advantage program, and the Congressional Budget Office estimates these cuts will force two million seniors off their current plans."

That's over half of Florida's Medicare beneficiaries:

	Florida	Nation
# Beneficiaries	3,180,256	44,831,390

Source: StateHealthFacts.org

Does Medicare get better physical therapy for their 113% premium?

No.

Medicaid to Medicare

"Starting in 2014, anyone with an income below 133 percent of the poverty level — or about $29,327 in 2009 for a family of four — will be eligible for a rejuvenated Medicaid program.

Medicaid’s often anemic reimbursements will be increased to the same level as Medicare, making more doctors willing to accept it."

The shift from unprofitable Medicaid to profitable Medicare will further help private practice physical therapist providers in the state of Florida - probably more than in northern states because in Florida Medicare is the most profitable payer.

Many providers threaten to drop Medicare if the Congress drops reimbursement too low but for many providers that is simply not an option - Medicare is our best, highest margin payer.

Medicare is statutorily obligated to remit payment within 14 days of receipt of a 'clean claim' - with electronic billing services these days every claim is a clean claim.

Tax credits for small PTPP's

Finally, tax credits instead of deductions may help small businesses that provide their employees with healthcare benefits.

From the March 25th USA Today...

"Companies with no more than 25 employees and average annual wages of $40,000 could receive tax credits to help provide insurance to employees.

There is a catch, of course.

The business must pay 50% of employees' premiums..."

Not every PTPP will benefit from these changes and we may not see some of these changes for many years.

What are your thoughts about health system change and how will it affect physical therapists?

Improper Payments the Focus of Obama's Speech

President Obama, in his Wednesday, March 10th, 2010 speech in St. Louis, Missouri, unfortunately chose to focus on Medicare inefficiencies and the estimated $100 billion dollars in 2009 improper payments as the main means to cost control and a way to pay for his proposed reform efforts.




Worse, he chose to laud the Recovery Audit Contractors (RACs) as potential saviors of healthcare and a major source of cost savings in his healthcare reform proposals.

The Improper Payments Elimination and Recovery Act (originally introduced in 2009) is designed to introduce RAC-style auditors to other, high-cost areas of government spending, like military defense and education.

When, in fact, the problem is not mainly inefficiencies in payment but the system itself: fee-for-service creates incentives to overutilize, overspend and overtreat.

Obama's health care reform has been appropriately criticized as health care financing reform.

An outcomes-based system for medical payments is years away and the transition is likely to be gradual and phased-in.

America has the highest health care 'unit prices' in the world but a middling rank in total outcomes (#34).

Rather than cast auditors as heroes (which, by contrast, paints doctors, hospitals and physical therapists as villains) let's put our efforts into accelerating the transition to real health care reform - outcomes.

Is it time to replace Fryette's Law with Bayes' Theorem?

These conflicts will drive physical therapists' decisions and actions for the foreseeable future:

Qualitative vs. Quantitative

'Skilled physical therapy' can be dichotomized into two camps: the probabilistic camp that embraces evidence based medicine (EBM), future risk analysis, clinical prediction rules, estimates of effect sizes and other modern tools.

Here's an example...

The other camp is the movement impairment camp that believes the penultimate physical therapist skill set is verbal and tactile feedback (same as it was in 1992).

Here's an example:

"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 division can be summed up as a 'qualitative' vs. 'quantitative' skill set - the old way was exclusively the former while the future is increasingly the latter.

Top Down vs. Bottom Up

Even in physician circles there in not universal accord on standards like clinical prediction 'rules': only 40% of Emergency Room student doctors use clinical prediction rules; only 60% of Emergency Room resident doctors use them.

The doctors cite 'complexity' as the reason why they don't use the 'rules'. Some therapists advise using simple clinical templates to avoid 'stifling' complexity.

You can get some of my simple (free) EBM physical therapy (paper) templates here.

This lackluster support has motivated some authors to call for a 'top down' mandate on the use of 'rules' for clinical decision making.

Many physical therapists in this listserve resist 'rules' that they believe infringe on their autonomy.

Many of us learned about evidence based medicine from a benign, 'bottom up' perspective:

1. form a relevant clinical question
2. identify your target patient sample/population
3. search the literature
4. consider your patient's values/goals
5. apply the best available evidence in a judicious manner to your patient

Can a 'top down' model of evidence based medicine work with an autonomous physical therapist? Will clinician non-compliance force government and third party policymakers to mandate EBM standards for payment?

Private vs. Corporate

Is high volume + high quality physical therapy possible?

Many PTs believe 1-on-1 patient care for one hour is the epitome of 'quality'. We're taught in PT school that anything less is 'unethical'.

Many large, corporate clinics rely on low paying, commercial insurance (Aetna, United, BCBS/Anthem California, etc.) to achieve high volume and high revenue.

What about the ethics of outcomes? Should the patient get to choose? What if PT#1 get great results (outcomes + patient satisfaction) treating 4 patients per hour while PT#2 gets lackluster results 1-on-1?

Have some, select PT managers solved the high volume + high quality equation?

Until we reach an 'outcomes-based healthcare system' this is a rhetorical question. Some relevant bellwethers may illustrate my point:

1. Spanish Physical Therapists - 100% of private practice PT in Spain is cash-pay. No Spanish Medicare payments go to small PT clinics - only to large, often hospital-based, PT clinics. Small practices refuse to accept Medicare due to the low reimbursement. This is true for Spanish private practice physicians as well.


2. USPh - record net revenue in 2009 of $201 million due mainly to increased patient visits and $102.85 per visit collections. How do they do it? Does it matter? As long as the patient gets measurably better and is satisfied with their care.


3. MD PT Partners - this firm takes a percentage, in perpetuity, for setting up a high-volume patient pipeline that aligns the financial incentives of the physician and the physical therapist. It's probably not illegal. Is this wrong? Only outcomes will tell the full story.

Government Process vs. Personal Process

Medicare process measures include the following:

1. the 8-minute rule
2. the -kx modifier
3. 'skilled therapy' (as determined by an 'expert' auditor)
4. time-in & time-out
5. PTA supervision requirements based on treatment setting
6. Minimal Documentation Requirements
7. 'one-on-one' codes
8. physician certification of the physical therapy plan of care
9. et al

Personal process measures are demonstrated by the physical therapist who says...

"I can only see one patient per hour..."

Quality needs to be primarily determined by the patient (the customer) and the outcome - not primarily by process.

Mechanistic vs. Probabilistic

Mechanistic models are good for students and generalists - most PTs are specialists. Many of the new evidence-based 'rules' go right to a prognosis and skip the diagnosis altogether.

Examples of biomechanical models that help students are...

• "The disc is a jelly doughnut..."
• The sacro-iliac joint 'locks' and 'unlocks'.
• Fryette's 'Law' describes the behavior of diarthrotic joints undergoing therapist-directed mobilizing forces.

Most of us learned these models in PT school. I learned them in 1992.

Probabilistic thinking in medicine is often described by Bayes' Theorem - start with a probability (prevalence) and update it with an observation or test that confirms or rules out the diagnosis.

Physical therapists are being held to new standards - we are expected to make decisions like doctors.

Is it time to replace Fryette's Law with Bayes' Theorem?

Can physical therapists traditional decision making styles guide us through the conflicts that await us?

New MedPAC report rough on Physical Therapy home health

Just when your payment problems couldn't get any worse...

The new Medicare Payment Advisory Commission report issued today (March 3rd, 2010) recommends some troublesome actions for home health agencies:

• ...The number of agencies continues to increase, with about 500 new agencies in 2009...(p. 21)


• ...the Commission has concluded that home health payments need to be significantly reduced.
  
  To start with, the Commission recommends a zero update for 2011...


• ...the Congress should direct the Secretary to review home health agencies that exhibit unusual patterns of claims for payment...

Some encouraging findings...

• The Home Health Compare measures for 2009 are similar to those for previous years, showing improvement in the functional measures and mostly unchanged rates of adverse events.

More to come...

Unlike Congress, MedPAC is trying to reduce overall Medicare costs. "Payment adequacy" means that you're making enough money this year and next year you can afford to make less.

One proposal in Health Care Reform was to make MedPac a cabinet-level, administrative body, like the Federal Reserve. Now, MedPAC only makes recommendations to Congress.

Maybe we need to keep it that way.