"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

Monday, August 30, 2010

Is the United States Government Biased Against Private Practice Physical Therapists?

I've thought about this subject for several months - ever since March 2010 when MedPAC delivered its annual Report to the Congress: Medicare Payment Policy.

Now comes this recent article from The Annals of Internal Medicine, picked up on the Evidence in Motion blog, that verifies the implications of the MedPAC report and my suspicions.

The report was black and white evidence that our government is biased against small healthcare providers - where 70% of American healthcare takes place!

Medicare "guess-timates" on adjustments to the Physician Fee Schedule based on access to capital markets for selected healthcare sectors.
"Substantial increases in the number of providers may suggest that payments are more than adequate and could raise concerns about the value of the services being furnished...

The volume of services can be an indirect indicator of beneficiary access to services...

Volume is also an indicator of payment adequacy; an increase in volume beyond that expected for the increase in the number of beneficiaries could suggest that Medicare’s payment rates are too high."

Providers’ access to capital

"Access to capital is necessary for providers to maintain and modernize their facilities and capabilities for patient care.
Widespread inability to access capital throughout a sector might in part reflect on the adequacy of Medicare payments (or, in some cases, even on the expectation of changes in the adequacy of Medicare payments).
However, access to capital may not be a useful indicator of the adequacy of Medicare payments when the sector has little need for large capital investments, when providers derive most of their payments from other payers or other lines of business, or when conditions in the credit markets are extreme."
Guess what? Small clinics like mine and yours DON'T have access to the capital markets! These days we may not even have access to bank lines-of-credit anymore!

The MedPAC report implies that only large firms with scale economies, access to capital markets and administrative staff that can maximize revenue and compliance will succeed in the future.

The Annals article, titled The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges was written by physicians with close ties to the present administration. Their opinion echoed the MedPAC report:
"The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.
The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience."
No rebuttal was printed by the Annals editors but many online readers voiced vigorous opposition to the politically positive tone of the Annals article.

Physical Therapists and the Multiple Procedures Payment Reduction Policy (MPPR)

The recent, proposed Multiple Procedure Payment Reduction (MPPR), is just the end result of policy discussions at high levels that those of us in private practice can only react to - we usually don't get a voice in these decisions.

Hopefully, many of us wrote letters to the head of the Centers for Medicare Services, Dr. Donald Berwick, pointing out that the projected 13% revenue "savings" will be disasterous for private practice physical therapists and their patients.

Here is a copy of the letter I sent.  The comment period closed August 24th and we'll learn the final adjudication November 1, 2010.

Take Home Message

I don't think the future of physical therapy belongs just to large firms - private practice physical therapists can still effectively compete.

The Annals authors, however, do not believe managing future change is possible in small practices:
"Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."
They appear to have reached the conclusion already that small businesses in medicine and physical therapy will go the way of the dinosaur.

In order to prevent our own extinction we will need to gain control of the one thing that we have that the government wants - our patient data. We need to control not just outcomes data but also baseline data on patient characteristics that affect outcome. Also, we need to show that our decisions on patient care are BETTER than physicians decisions.

Why are physicians referring patients to us? We should be referring patients to them! We should be the point of entry!

But, to gain control of our data we will need better systems for managing data.  Not just Electronic Medical Records (EMR). And not just Clinical Decision Support (CDS) systems, either.

We'll need a marriage of EMR and CDS that will improvement the process of care - as delivered by physical therapists.  We'll need to show that ONE care process in particular: care delivered hands-on by physical therapists DOES lead to better outcomes.

While outcomes are difficult to measure, process measures are much easier. I have not been especially happy with many burdensome process measures in physical therapy but hands-on care is a "no-brainer".

This new study in the August 2010 Physical Therapy Journal is just the second published article showing that PT process measures improve patient outcomes.

What to Do?

Ask your EMR vendor about integrated decision support - what are you doing with your data?  If you don't have an EMR you can still use pen-and-paper decision support tools - usually paper templates - that can be stored in the patients' chart.

These templates can be set up to predict the duration, frequency, total cost and expected outcome. Baseline co-factors can alert us ahead of time to those patients at risk for "failing" in physical therapy - these are the "outliers" that Medicare so desperately wants to identify.

Some "outliers" will need more therapy, some will need referral to psychological screening and some will need surgery.

I hope we can convince the Congress soon that the most efficient setting for physical therapists to serve Americans in this way is often the small, outpatient physical therapy office.

Thursday, August 26, 2010

What Kind of Decision Maker are You?

Jill was a bright new PT graduate with a quick smile and a winning personality. She had worked her tail off in physical therapy school and she had a head full of knowledge she was ready to use.

Jill was especially keen on treatment based classification and new clinical decision rules. Her training surpassed the education of many of her older peers, though, and she was sensitive to their professional pride when making her treatment recommendations. Nevertheless, Jill was "on fire" to use her new skills and she did so with gusto - impressing her patients and the rest of the staff with her authority and her good results.

Bill was Jill's boss. Bill was a seasoned expert in many therapy settings - currently he worked as Director of Rehab in a hospital outpatient department and treated patients about half of each day.

Bill had also learned about the new clinical decision rules through some directed self-study and had used the rules on some of his patients.

After 20 years of treating patients, however, Bill felt that he could do just as good as the rules in predicting treatments - he had even subjected his judgement to his own little test.

He evaluated some patients with his judgement and then measured them using the rule - he found that his judgement matched the rule almost all of the time.

Bill had seen many new graduates and he recognized Jill's enthusiasm but he also noticed that she seemed to have something different from the other new graduates he had mentored - more than just enthusiasm and intensity - Jill also had a systematic approach to measuring her patients and making decisions.

Their differences came to an impasse when Jill requested that Bill create new, computerized templates for the hospital electronic medical records (EMR) program. Jill needed specific outputs, such as expected frequencies, duration and outcomes based on her patients' individual data.

Jill had been entering her data into the EMR but the data just sat there - nothing was printed on the Plan of Care that went to the physician for signature. Jill wanted the EMR to automatically interpret her data based on existing decision rules and make recommendations. Jill had to manually enter her recommendations using free text typing which took valuable time away from patients.

Bill knew that Jill's request would be problematic:
  1. software coding for the EMR would cost money,
  2. no therapist consensus existed on the need or the efficacy of TBC,
  3. the literature on TBC was incomplete
  4. and many, experienced staff would resist changing their documentation habits based on the recommendation of a new graduate.
What Should Bill do?

Jill uses quantitative models to make her decisions. Quantitative decision making is on the rise in healthcare - although providers, especially physicians and physical therapists - still have a ways to go in improving our decision making fidelity.

Bill, however, uses qualitative decision models that are the hallmark of experienced professionals in many fields.  There is substantial evidence that physicians use qualitative over quantitative decision models. According to the University of Texas Medical Informatics Department physicians...
  1. have difficulty with quantitative reasoning
  2. have difficulty diagnosis using Bayesian analysis (making diagnoses based on prevalence, test results and posterior probabilities)
  3. have difficulty interpreting effectiveness of treatments
  4. have difficulty estimating probabilities (and, as a result, infrequently use probabilities in practice)
As a result of these deficits in quantitative reasoning physicians may...
  1. order excessive, expensive and invasive diagnostic tests
  2. incorrectly interpret the test results
  3. inconsistently interpret the post-test probabilities of disease
  4. make inconsistent treatment decisions
  5. and over-treat conditions with infrequent poor outcomes
Decision researchers usually contrast quantitative vs. qualitative decision making although decision researcher Gary Klein, in his book Sources of Power, uses the term "naturalistic" instead of qualitiative.

Naturalistic decision making (also called "pattern recognition") has also been criticized over the last 25 years in decision research as computers and "computer-like" decision algorithms have become more popular.

Klein argues that both models are helpful and uses the metaphor of peripheral and foveal vision to illustrate that naturalistic decision making is a "wide angle" approach that captures all relevant (and some irrelevant) data while quantitative decision making (TBC/CDR) is a "narrow" approach that captures only relevant data and rules out all other options.

Klein presents the case that naturalistic decision makers in fields as diverse as...
  1. US Navy missle defense and flight commanders
  2. Firefighters
  3. Chess grandmasters
  4. Smokejumpers
  5. Nuclear power plant risk managers
  6. Software designers
  7. Corporate CEO's
...do not use quantitative models for over 90% of their decision making tasks. Instead, these experienced experts rely on naturalistic decision making to manage their day-to-day tasks.

Which is Better?

The current healthcare crisis may imply that "something" needs to be done and perhaps improving our decision making models will improve...
  1. costs
  2. outcomes
  3. medical errors
  4. provider liability to audits
  5. provider liability to medical malpractice
  6. efficient allocation of societal resources
There is good evidence that costs, outcomes and medical errors can be improved using CDR. Current data suggest that the medical error rate across various settings and geographic regions are similar:

RegionError Rate
Great Britain3.7%

Error rates in industries that have implemented computerized clinical decision support, however, are markedly different:

IndustyError Rate
Airlinesless than 0.01%
Bankingless than 0.01%

What Did Bill Do?

Bill could see the writing on the wall - he knew the day of pure naturalistic decision makers in healthcare - the old guard who relied on "gut instinct" and experience to provide care - was coming to an end. Cost pressures and the enthusiasm of people like Jill would usher in a new dawn that used computers and algorithms for the simple decisions. He hoped he would still have a role to play.

When Bill watched Jill at work he felt better - if the future depended on people like her then he knew that physical therapy was in good hands.

Sunday, August 22, 2010

How Can I "Sell" the DOTPA 17-page Physical Therapy Evaluation to my Friends and Peers?

I've a confession to make...

I once tried to go to work for Stryker Corp. This was back in 2005, before I decided to make the big commitment to private practice physical therapy.

Stryker Corp. are the folks who make prosthetic hips, joint cement, screws and locking systems for joint fusions. Their customers are orthopedic and neurosurgeons who have among the most expensive pens in all of medicine.

My Stryker contact made me take a test called the StengthsFinder Test. The point of the test was to identify the strengths of those people who would make a killer salesperson:
  • Achiever
  • Competition
  • Interpersonal
  • Stimulator
  • Persuasion
Although neither Stryker (nor Gallup) will reveal their criteria for hire I believe these listed above are the attributes of a killer salesperson. Needless to say, I did not test high on some of these qualities.

The qualities I tested high on were the following:
  • Achiever
  • Input
  • Learner
  • Strategic
  • Context
According to my Stryker contact, these are the qualities that make for a good college professor. Oh well, I didn't really want to be a salesperson anyways...

Which brings me to the point of this blog post, which is that I just participated in the:
Centers for Medicare and Medicaid Services
Special Open Door Forum: Developing Outpatient Therapy Payment Alternatives (DOTPA) - Data Collection Update
...and now I have to go "sell" the new DOTPA 17-page physical therapy evaluation form to my friends, staff,and peers. I have to sell this form that may...
  1. add to their paperwork burden
  2. cannot be used as part of the medical record
  3. is not electronic
  4. carries no additional reimbursement...
One of the benefits of participating in this voluntary initiative is that clinics and hospitals will receive a 6-month "holiday" from Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) record requests.

Another benefit to participating is that PTs will be among the first to "climb the learning curve" of the new Medicare alternative payment system that is due by May 2013. Physical therapists in Private Practice (PTPP) are among the last to learn these new programs because of time and resource constraints.

Here is the DOTPA slideshow from the August 19th Open Door Forum:

So, are the RAC/MAC holiday and documentation skills the only two features of DOTPA that I've got to sell to my staff? And, are time and administrative capacity the two biggest constraints that PTPP's have in implementing the new Medicare DOTPA 17-page evaluation?

What about selling skills?

How would you "sell" this new program to your staff and peers?

Monday, August 16, 2010

Physical Therapist Payment Options #3

This is the third option discussed in the 2011 Proposed Medicare Physician Fee Schedule published in the Federal Register on June 25th, 2010 and open for public comment until August 24th 2010.  I discussed Option # 1 and Option #2 in previous blog posts.

You can submit your comments directly to Medicare using this link. According to the American Physical Therapy Association (APTA):
If you attach the document, please make sure to include a statement in the text box (e.g. “I am attaching comments in response to the proposed physician fee schedule rule. Thank you for your consideration.”)
Please note that this blog is independent of the APTA and my opinions or blog posts are not in any way associated with the APTA.

Option #3

Twelve new Evaluation and Intervention (E/I) codes that would capture the History, Physical Examination and Medical Riskiness of the physical therapy evaluation.

Evaluation/Assessment Complexity
Intervention LevelMinimalModerateSignificant
NoneE/I code #1E/I code #2E/I code #3
MinimalE/I code #4E/I code #5E/I code #6
ModerateE/I code #7E/I code #8E/I code #9
SignificantE/I code #10E/I code #11E/I code #12

A Significant complex evaluation with Significant interventions would rate a #12 E/I code - the highest payment. Most of the PT diagnoses would be codes #4-9. Also, only physical therapists, physicians or non-physician practioners could bill codes #1-3 and #7-12. Physical therapy assistants could also bill codes #4-6.

Physician Evaluation and Mangement codes are discussed here and using the Interactive Worksheet at First Coast Service Options (Florida Carrier/Intermediary).

Benefits Option #3 represents the closest approximation to physican Evaluation and Management codes that are valued based on...
  • History
  • Physical Examination
    • based on the number of body systems reviewed and
  • Medical Decision Making that looks at
    • Number of Diagnoses
    • Amount of Data reviewed (eg: lab results)
    • Risks associated with medical decisions
Holding physical therapists accountable to this standard of decision making can improve our professional autonomy by increasing the demand for data collection.  Basically, the more data you collect the better your reimbursement rate.

Moving away from Fee-for-Service in this way may reward quality over quantity.  Is it possible that the very best physical therapists could see HIGHER reimbursements as they learn the new system and finally get paid better than their "average" peers?

Risks Physicians overutilize testing, mainly diagnostic imaging, in order to reduce professional liability. This reliance on expensive, modern testing drives up healthcare costs and increases the incidence of false-positives, physiologic diagnoses and inappropriate surgeries.

Fortunately, physical therapists do not share this risk. Greater data collection to reduce Medciare Audit risk SHOULD be a goal of any alternative payment system.

Bundled payments, however, are unfamiliar to most small medical providers and may provide inadequate reimbursement for the most complex cases.

Time Frame: 2 to 4 years to implement.

My Call: This is an option I would like to see discussed further - if only for the reason that it suggests that physical therapists can and do make decisions of similar comprehensiveness, complexity and riskiness as physicians.

Friday, August 13, 2010

Physical Therapist´s Payment Option #2

This is the second option discussed in the 2011 Proposed Medicare Physician Fee Schedule published in the Federal Register on June 25th, 2010 and open for public comment until August 24th 2010.  The first Option is discussed here.

You can submit your comments directly to Medicare using this link. According to the American Physical Therapy Association (APTA):

If you attach the document, please make sure to include a statement in the text box (e.g. “I am attaching comments in response to the proposed physician fee schedule rule. Thank you for your consideration.”)
Please note that this blog is independent of the APTA and my opinions or blog posts are not in any way associated with the APTA.

Option #2

A new PT therapy cap will be determined "...based on existing therapy utilization...

  • such as limits to the number of services per session,
  • per episode or
  • per diagnostic grouping...".
Benefits: None are obvious to me. This seems like 2006 Therapy Cap Redoux

Risks: Plenty. The risk of a Medicare Audit if you appeal the automatic denial (no -KX modifier with this option) and deliver needed therapy services to thosepatients who need them.

The therapist is left holding the bag with no ability to justify needed services beyond the technology that exists today.   Physical therapist liability is increased, documentation burden is added and no financial improvement is evident.

As I identified in Option #1, PT liability is incurred because Medicare Auditors can deny services day-by-day or even line-by-line based on their arbitrary determination of "skilled physical therapy".

Time Frame: 1 to 2 years to implement.

My Call: Option #2 is just the same old, same old - again, a redoux of the 2006 Manual Exceptions process that confused many therapists and left the patient, in many cases, without needed services beacuse the regulations were too confusing.

Wednesday, August 11, 2010

Physical Therapist´s Payment Option # 1

Three new poposed payment options related to the Medicare Physician Fee Schedule were published in the June 25th Federal Register and are available for public comment until August 24th.

The immediate concern is the proposed Multiple Procedure Payment Reduction (MPPR) policy but there are additional concerns that deserve physical therapists´ attention. I´d like to review the alternative payment options:
  • Option #1
  • Option #2 and
  • Option #3
...and make recommendations for or against. As always, your comments are welcome on this blog. Also, please use the link provided to make public comments on the proposed MPPR policy directly to your government.

Note that CMS is not specifically recommending these alternative payment policies, at this time.

Option #1: New Severity and Function codes

The Centers for Medicare Services (CMS) would require physical therapists to replace the -KX modifier with new HCPCS Level 2 codes at Evaluation and Progress Note intervals (30 days or 10 visits, whichever is less).

PT Test or MeasureFunction CodesCode Description
Impaired Step Down TestGxxxUBody Function/Body Structure impairment - current
Impaired Step Down TestGxxxVBody Function/Body Structure impairment - goal
Slow Stair Measure Test (9 steps)GxxxWActivity Limitation/Participation Restriction - current
Slow Stair Measure Test (9 steps)GxxxXActivity Limitation/Participation Restriction - goal
3 steps into homeGxxxYEnvironmental Barrier - current
3 steps into homeGxxxZEnvironmental Barrier - goal

note: I have added the PT Tests and Measures to show how these codes might be supported by evidence-based data in the patient chart.

Two severity modifiers have been proposed. This first chart shows modifiers based on the ICF:

Severity ModifierDescriptor

This second chart shows modifiers for impairments, limitations and/or barriers as simple percentages:

Severity Modifier
1 to 19%
20 to 39%
40 to 59%
60 to79%
80 to 99%

Benefit: The policymakers are using International Classification of Function (ICF) descriptors to link physical impairments to function in a way that can be analyzed through claims reporting.

This option explicitly defines patient progress by comparing current and expected (goal) function.

CMS believes this option will lead to a decreased reporting burden because the -KX modifier would not be need on each claim line for patients over or near the PT caps.  Instead, only the new severity and function codes would be reported at (re)evaluation and Progress Note intervals.

These codes would also provide more information for medical review - at this time medical review (Medicare Audit) is a highly variable process that imposes provider liability based on largely pen-and-paper scribbled, narrative notes.

Risk: Physical Therapists in Private Practice (PTPPS), hospitals outpatient departments (Part B) and other settings may not routinely assess firsthand patient environmental barriers, especially those in the patient´s home.

Also, the link between physical impairment (body structure and function) and functional limitations (Activity and Participation Limitations) is tenuous and poorly described in the PT literature.

If such a link does exist it is probably NOT the linear, staight line conceptualized by Nagi in 1965 or the ICFDH in 1981.

This new coding scheme seems to hold physical therapists accountable for a conceptualized framework that is popular to academics and policymakers but is often absent from clinical realities.

Time Frame: Six months to two years.

My Call: I like this option because it gives physical therapists the chance (for the first time) to send claims-level data to CMS about the quality of physical therapy. 

This option may protect physical therapists from the Medicare Auditors´ concept of "skilled physical therapy" as a reason to deny claims.

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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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