Challenges for Physical Therapist Managers

A physical therapist manager friend of was telling me about his expensive laser and spinal decompression devices and how much they helped his patients. He also mentioned how much money he was making at his two clinics.

He then asked me about the recent changes to healthcare and how they would impact physical therapists.

I told him that the next 3-10 years would bring about a gradual shift from Fee-for-Service to an outcomes-based payment system. A payment system based on patient-reported outcomes will create winners and losers in physical therapy.

Winners: physical therapist mangers with a unwavering focus on patient reported functional outcomes (PRO).

Losers: physical therapist managers that produce QUANTITY but not QUALITY. My friend may lose if he doesn't shift his focus away from his procedures, like laser.

Note: There may be some high-quantity providers who can also generate high-quality outcomes, in fact, there probably are - these are the physical therapist managers who have developed efficient, effective processes for managing patients, getting them better and making money, too.

I challenge providers to identify yourselves if you think you've mastered the process of creating great outcomes. Unfortunately, verifying your claims will be difficult since even the leading PRO provider commands only a tiny market share of the PT industry. That's too bad.

Better management processes are the key to winning vs. losing. My friend thinks that his procedures, like laser, are the keys to quality - but they're not. It's the management process.

The question for the future will be this: Who controls the process of care? Physical therapist managers or the government? Right now the government dominates the process of care with mandates on 'how' physical therapy is delivered. Processes like...

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

The biggest challenge in transitioning to an outcomes-based payment system will go to physical therapist managers. It's the physical therapist managers who have the tough job of...

• maintaining high productivity,
• good documentation compliance,
• high staff morale and
• excellent clinical outcomes
• creating management processes that make money and deliver good PRO

Where Do We go From Here?

Costs are increasing but patients, in aggregate, are getting worse. Spine problems in the United States especially are getting worse. This article from the October 2009 Spine magazine states:

"National expenditures for spine problems increased 82%, or an average of 7.0% per year, from 1997 to 2006.

Paradoxically, measures of self-reported mental and physical health and activity limitations among those with spine problems worsened, and the percentage of respondents with spine problems who reported work, social and physical functioning limitations increased substantially during this period."

Physical therapist managers don't know which treatments work and which don't for each patient. From the British Medical Journal, 51% of all medical interventions are of unknown effectiveness.



Physical therapists are good at creating high levels of patient satisfaction (one measure of quality) through caring, face-to-face interaction and hands-on care.

But which interventions create better value? Which create better patient reported functional outcomes? Better patient satisfaction? Lower costs while keeping people living independently? Reduce the risk of future adverse events? Do these following interventions do any of the above?

• Ultrasound
• Laser
• Spinal Decompression therapy
• Myofascial release
• Craniosacral therapy

We know, in general, ultrasound and electro-therapeutic modalities tend to decrease functional outcomes. Maybe my friend's laser and other expensive tools will improve his outcomes, I don't know. It's not my role to say so...

That is the challenge for the physical therapy manager.

Doc Fix will affect physical therapists, too

We done this three times already in 2010 but the 21.29% cut in the Medicare Physicians' Fee Schedule is again scheduled to go into effect on June 1.

To prevent the cut, The American Jobs and Closing Tax Loopholes Act of 2010 (the 'Doc Fix') (HR 4213) is scheduled for a vote this week.

Dr. James Rohan, President of the American Medical Association, explains and defends the 'Doc Fix' in this C-Span video.

Passing HR 4213 will cost more money. The Doc Fix will...

...increase budget deficits by about $115 billion for fiscal years 2010 and 2011 and by about $84 billion over the 2010-2015 and 2010-2020 periods...

Dr. Rohan's position is that current Medicare rates are 20% under a break even cost to keep our offices open.

HR 4213 proposes a 3.5 year payment increase, so long as cost growth on services doesn't grow too much.

After 2013, payments will update consistent with the current law. That means in 2014 doctors and private practice physical therapists will see a dramatic 30% reduction in payments.

What is the role of the Physical Therapist's Diagnosis?

Another take on the problem of regional variation, excessive diagnostic testing and paying for quality...

A new study in the May 12th New England Journal of Medicine revealed a 'striking' new finding: that Medicare patients who move to high-intensity healthcare regions in the USA get diagnosed with more diseases, appear sicker and, ultimately, receive more invasive testing and diagnostic imaging services.

Excessive diagnostic testing is a problem because it increases costs and leads to unnecessary procedures.

Going forward, Medicare's Pay for Performance scheme will morph into a true outcomes-based health care system and will rely on diagnostic 'risk adjustments' to pay hospitals, doctors and physical therapists that treat sicker patients.

Some of these 'sicker' patients just appear sick because doctors are diagnosing too much - because they are paid to do so.

An example given in Dr. Maggie Mahar's The Health Care Blog of Regional Variations in Diagnostic Practices by Dr. Yunjie Song et al of men diagnosed with prostate cancer reveals that most of these men will never experience symptoms and will never need advanced cancer treatment (eg: surgery).

Subsequent outcomes measurement of treatments given to these men will reflect their cancer diagnosis and will increase the hospital's 'risk adjusted' payment - even though these men may never get 'sick' from cancer.

Physical Therapy Diagnosis

In physical therapy, many treatments are performed (eg: electric stimulation, ultrasound, diathermy or heat/ice) based on a pattern recognition approach.

Pattern recognition is efficient but subject to cognitive bias such as the following:

• Anchoring - you believe that ultrasound is an appropriate treatment for your current patient because you were taught this approach in PT school.
• Confirmation bias - you believe that ultrasound is the appropriate treatment for your current patient even though your patient mentions that they have used this modality previously to NO effect.
• Availability heuristic - you believe your current patient is a candidate for ultrasound because your last patient got better with ultrasound and she "just loves" ultrasound.

The alternative to pattern recognition is a 'rational analysis' approach - in Physical Therapy the best example of rational analysis is Treatment Based Classification (TBC) - where the physical therapist measures several, fundamental patient characteristics and 'decides' on a particular treatment approach.

An "ultrasound" decision rule could identify who WILL NOT benefit from ultrasound. Alas, no such rule exists.

No TBC rules exist for other vague, high-frequency conditions seen in physical therapy either, such as:

• future falls risk,
• general conditioning and
• pain control.

Physicians testing for pathology usually involves invasive, irradiating or expensive procedures which begs the question in medicine: Is more testing better? Does a medical diagnosis improve your chances? Does more healthcare lead to better health?

Diagnosis or Prognosis?

Fortunately, physical therapists already have tools to assess factors that contribute to outcome - and the authors of the diagnostic variation study seem to be aware of the importance of these tools...

“...measures of health risks reported by patients (e.g., smoking and exercise patterns) and functional status (physical, social, and role function) could be incorporated in risk-adjustment models.”

It seems likely that physical therapists, unlike physicians, could benefit their patients by additional testing, measurement and diagnosis of patient characteristics that contribute to outcome.

It also seems likely that the new role of the physical therapist under an outcomes-based healthcare system will be that of diagnostician: searching for risk factors that predict the outcome of an episode of physical therapy care, rather than primarily delivering interventions.

Is it possible that your search for diagnoses will be rewarded similar to, but more consistently, to the way physicians are rewarded for diagnosing today? And if diagnostic variations can be 'evened out' can we assume that this new system will be equitably rewarding for the patient?

A state Senator teaches Physical Therapists how to lift correctly

Florida Senator Mike Bennett (R-Bradenton) came to Medical Arts Rehabilitation, a private practice physical therapy clinic in Palmetto, Florida from 4-6pm on Tuesday May 18th.

The Senator is the fifth from the left.

He gave about 20 physical therapists and physical therapist assistants a wide-ranging tutorial on the political process and how physical therapists can create change for our patients, for our practices and for our future.

Making political friendships along common interests and combining their money and number of voices was the overall theme of Senator Bennett's talk.

Some of the highlights of the Senator's talk:

• He was surprised to find out that orthopedic surgeons can still legally operate POPTs, imaging facilities and clinical laboratories in Florida since the passage of the 1992 Florida Statute 456.053 Financial arrangements between referring health care providers and providers of health care services.
  
  Doctors are exempt from the 1992 self-referral law if they meet two simple criteria:

They employ the physical therapist and only treat the doctors' patients - no outside referrals.

They are physically on-site at all times when patients are being treated.

• Free Money!
  
  One of the only pieces of healthcare legislation to pass the 2010 session was the Medicaid Anti-Fraud bill that promises to save 25% of the entire Medicaid budget.
  
  To legislators worried about a state budget with falling revenues and no chance of raising taxes the thought of putting bad guys in jail and GETTING PAID to do so is very attractive.
  
  One provision of the Anti-Medicaid Fraud legislation prevents close financial arrangements between physicians and home health agencies.
  
  
• One suggestion was to revisit the 1992 legislation with the intent of preventing close financial arrangements between physicians and other providers like PT, imaging and labs, similar to the 2010 Anti-Medicaid Fraud law.
  
  
• The Senator suggested creating alliances with like-minded constituencies that face similar challenges from physicians, eg:

Audiologists

Optometrists

Radiology services

Insurance companies (surprise, surprise!)

"It's too big to lift by yourselves", he said. "You can't do it alone, you'll need to make friends".

Imagine that, a state Senator teaching physical therapists how to lift correctly.