"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

Friday, July 30, 2010

A Sample Letter from a Private Practice Physical Therapist to Dr. Donald Berwick

...thanks to Melissa Manzione and a well-timed e-mail blast from the American Physical Therapy Association (APTA). Any credit for the value of this post goes to them. The errors are my own.

Dr. Donald Berwick
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–1503–P
P.O. Box 8013
Baltimore, MD 21244–8013.

Re: Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011. (CMS-1503-P)

Dear Dr. Berwick,

I live and work in Florida where about 70% of my patients are on Medicare. I own and work in a private practice in the outpatient setting where our primary interventions are...
  • preventing falls in the elderly
  • preventing other future adverse events predicted by current findings
  • preventing or reducing institutionalization by improving physical strength and function
  • and providing an alternative to expensive and risky surgeries.

I am greatly concerned about the recent proposed changes to the Medicare Physician Fee Schedule published in the June 25th Federal Register and due to go into effect January 1, 2011. Specifically, these changes affect outpatient physical therapists by recommending a proposed Multiple Procedure Payment Policy (MPPR) that reduces my reimbursement by 50% for each procedure after the first billed in the same day. Typically, physical therapists bill 4 procedures per day, in my setting.

In my community, Medicare is the fastest insurance payer with the highest profit margin. Medicare allows me to subsidize physical therapy services for many of the working class Americans with commericial insurance that pays at or below cost reimbusement to physical therapists in my setting.

This policy is ill concieved and unfounded based on the following points
MPPR Policy for Therapy Services is Based on Poor Policy Assumptions by CMS

CMS attempts to justify the MPPR policy because the agency believes there is duplication of services since physical therapists typically bill multiple CPT codes on the same date of service. This is incorrect. When the CPT codes therapists use were initially valued through the established and recognized American Medical Association’s (AMA) Resource Based Relative Value System (RBRVS) used by all health care professions, reductions were made to the practice expense component to avoid duplication and represent the multiple procedural nature of physical therapy practice.

In addition, CMS does not account for the multidisciplinary nature of therapy services or the patient’s clinical need for services in this policy

MPPR Policy for Therapy Services will Result in Draconian Cuts that Will Limit Patient Access to Needed Services

MPPR will result in a 12-13% cut to physical therapists under Medicare. This dramatic cut could have serious implications for both therapists and their patients. Practices may be forced to close, facilities may be forced to reduce their therapy workforce, and providers might seek strategies to reduce the number of Medicare beneficiaries they can see due to payment being under cost.

The implications for limited access to care for Medicare beneficiaries if these practice close or do not see these patients is clear and would occur immediately if the MPPR policy is implemented.

MPPR Policy for Therapy Services could have Workforce Implications

Currently, there is a shortage of physical therapists, occupational therapists, and speech language pathologists. Payment policies that cut payments below the cost of providing the services will exacerbate the shortage immediately by staff reductions and practice closings due to inadequate reimbursement and in the future as individuals consider health care professions.
America needs to reduce healthcare cost growth but these policy changes threaten to INCREASE costs if more Americans are institutionalized, suffer falls or increased disablement or received inappropriate surgery as a result of reduced access to physical therapy.

I urge you to reconsider your proposed physical therapy MPPR policy change in the interest of preserving Americans´independence, reducing costs and building a better healthcare system for the future.

Thank you for your consideration,


Tim Richardson, PT

You can post your letter to Dr. Donald Berwick using the snail mail address in the heading above or you can send your letter electronically to this link:


The comment period deadline is August 24th.

Wednesday, July 14, 2010

Physician´s Losing Political Clout is an Old Story

The American Medical Association appears to lack the ability to effect political change during this time of crisis and opportunity.  The AMA spent $6.2 million dollars in 2010 but was unable to move forward anything better than a 6-month "doc fix" that will expire on December 1, 2010 - after the mid-term elections.
“For the amount of money that AMA spends, it doesn’t seem to get the bang for their buck,”
...said a senior Republican health staffer who has worked with the group and was quoted at Politico.com .

Physician´s have been losing political clout for almost 40 years. For historical perspective re-read Robert Sandstrom´s The Meaning of Autonomy for Physical Therapy from PTJ 2007.

In his article, Dr. Sandstrom predicts health care reform as inevitable from society´s perspective:
"The position of near absolute control and authority over the health care system by organized medicine bred over time an insularity that ultimately led to a significant reduction in its dominance. As Krause remarked,
“No profession in our sample has flown quite as high in guild power and control as American medicine and few have fallen as fast.”
"The position of unfettered authority results in professional insularity, evidenced by a mission to protect itself, not the public and ultimately to lose support from policy elites.

Although medicine developed and implemented scientific changes that brought improvements in health, sometimes spectacularly, these gains brought significant other social costs.

While medicine maintains an important position of authority in the health care system, the response to this circumstance has been increasing involvement in health care by bureaucracies and weakened professional autonomy."
The AMA has traditionally strong ties to the Republican party but the Association itself is officially non-partisan. The AMA dealt it´s relationship with Republicans a severe blow in late 2009 with it´s early support for Democratic healthcare reform.

"Rep. Michael Burgess (R-Texas), a physician and AMA member, said the AMA’s early support for the Democrats’ health reform legislation tied his hands when he proposed health reform amendments to repeal the Medicare formula and put medical malpractice reforms in place." (Politico.com)
With the AMA on the ropes is it possible that physical therapists can rally to effect political change from the patients´ perspective and best interests?

Can the American Physical Therapy Association pool our efforts and dollars to improve healthcare and gain the trust of the "policy elites" that ultimately make the purchasing decisions in healthcare?

Could the APTA trade political support for the AMA for acquiesence on issues important to physical therapists? (eg: POPTs)

Do physical therapists have an opportunity to gain professional autonomy in this time of crisis?

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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.
No reproduction without authorization.

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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.