"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, December 27, 2010

A little help with Health Care Reform

I don't know if we know exactly how this new law will impact private practice physical therapists but this video gives a short, entertaining look at the timeline in a way that breaks down the objections on both sides of the divide...

Thank you to the good people at the Center for Medicare Advocacy, Inc.

Thursday, December 23, 2010

Physical Therapy Abuse by Miami Physician

I have two boys: seven and nine years old. When they start getting too fussy, I "separate" them and send one boy outside and the other boy to a friends' house. That seems to prevent the inevitable conflict.

Physicians and physical therapists involved in Medicare fraud seem to invite similar negative results.

This recent (Dec. 22, 2010) Wall Street Journal article highlights the dangers of physician-owned physical therapy (POPTS) as well as outright fraud by self-employed physical therapists.

This map, created by journalists at the Wall Street Journal (WSJ), show physical therapy billing "hotspots" in the USA: Miami, Houston and New York City.

The WSJ article goes on to describe physicians in Miami and Houston billing for physical therapy services and a physical therapist in New York billing $2.5 million to Medicare in a single year.

Maybe we should separate physicians and physical therapists?

One solution is to outlaw physician ownership of entities to which they self-refer (eg: physical therapy, clinical laboratories, imaging centers, etc). This only seems reasonable to most people.

variation in physical therapists' Medicare charges

The situation in medicine and physical therapy is that 1% of the providers give the other 99% of us a bad name. The opposite situation exists in politics where 99% of the politicians give the rest of them a bad name:)

The Federal government figured out the self-referral situation in 1989 (Starke I) and extended the anti self-referral rule to Medicare in 1993.

But, concerns that government was intruding too far into medicine and legitimate business arrangements allowed doctors to apply "exceptions" for in-office physical therapy services in 2005.

This Rock-n-Roll doctor took $1.8 million in Medicare in 2008, much of it from physical therapy, shake-n-bake treatments he prescribed for his patients.

The treatments were not done by physical therapists but by "office girls" that he "trained" himself. Medicare caved-in to POPT physician pressure when they wrote Federal licensure requirements:
"Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure."
Medicare doctor and rolls-royce
Another solution is to step-up anti-fraud efforts.

However, Recovery Audit Contractors (RAC) audits of providers find that inpatient hopitals, not Nigerians or Rock-n-Roll Doctors, are the largest source of cash to the RAC revenue generation scheme.

Inpatient hospitals are likely targets, not because of outright fraud, but because the system is too complicated, medical billing too technical and billing errors the result of mistakes not crime.

Who commits most of the crime in Medicare fraud?

It's not providers. It's not even fancy rock-n-roll doctors.

60% of healthcare fraud is due to the pharmaceutical industry and insurance companies.

IndustryRecovery(millions)Per Cent
Healthcare Provider$2,122.2538.8%

My kids don't know when to separate themselves so I do it for them and we keep peace in the family. How can we keep "peace" in our adversarial Federal healthcare system?

If we can't separate physicians and physical therapists then what about removing the requirement for the physicians' signature on the physical therapists' Plan of Care?

Isn't that the source of the conflict?

Sunday, December 19, 2010

Physical Therapists Find Difficult-to-Diagnose Pathology Better Than X-rays

In physical therapy school, they taught me that "objective" test findings are those not colored by patient bias.

We ask the patient for their "subjective" report that we, as medical experts, need to validate through the diagnostic process.

But, "objective" tests may be biased also.

X-rays are commonly referenced to illustrate the difficult dichotomy between "soft", subjective data and "hard", objective data.

When we make decisions we would like to have the high quality data, and then, if possible, consider other, lower quality data.

In diagnosing an x-ray, radiologists decision making is made up of two parts: Perception and Cogniton.

Perception is the physicians' eyesight, image quality, stage of pathology, training, experience, and possibly the prevalence of the condition in the population. These are all well-measured factors that we train in medical school, certify by government agencies or enforce through legal practice standards.

Cognition is less well-measured. Cognition varies by individual and, within individuals, cognition varies by time of day, mood, fatigue, knowledge of other patient factors, stress, time frame of the decision, setting of the physician and other "soft" factors.

Radiologists and X-ray Findings

Radiologists have a difficult job. In one study of mammography, their inter-observer reliability was only 48%. That's "moderate".

See this Medscape slideshow of difficult-to-interpret X-ray images of the lung.

Slide 13 of Easy-to-Miss Findings on Chest Radiographs shows a wedge thoracic compression fracture that can be missed on x-ray imaging.

A newly published decision rule by Henschke enables physical therapists to screen for vertebral fractures without the need for expensive and irradiating images.

Slide 14 of Can't Miss Critical Findings on Plain Chest Radiography shows a pulmonary emboli that broke off from a deep vein thrombosis in the leg.
"Of note, most chest radiographs are normal in patients with a pulmonary embolism".
Physical therapists can detects thrombotic blood formations before they turn into a hard-to-catch, deadly emboli using Well's criteria that will find blood clots with greater sensitivity that a physician's clinical intuition.

Physical Therapists' Findings

Even commonly used physical therapists' tests traditionally described as "objective" are less than helpful. Commonly used tests taught to orthopedic manual therapists for sacro-iliac dysfunction and SLAP tears have little predictive value.

In some cases, a negative test may be able to rule out the condition but cannot confirm the diagnosis. Physical Therapists Chad Cook and Eric Hegedus have written this excellent book to clarify some of the issues surrounding diagnostic accuracy.

However, some "subjective" tests are reliable most of the time. Consider that the test-retest reliability of the Oswestry Disablement Index is 0.99. Almost perfect.

In the proper selection of "objective" physical therapy tests and measures patient bias seems to be less likely than clinician bias.

Tuesday, December 14, 2010

California Physical Therapists Face New Challenges

There may be a opportunities for California physical therapists to purchase their employer physical therapy clinics for pennies on the dollar after a new ruling by the State of California Legislative Counsel found that physician-owned physical therapy clinics (POPTs) are illegal in California.

This ruling developed from stalled 2009 legislation put forth by podiatrists to add physical therapists to the list of professionals allowed to be employed in medical practices.

Physical therapists are currently NOT on the list and, as a result, the recent Legislative Counsel ruling determined that their participation in these businesses is illegal.
"The existing California Corporations Code does not specifically include physical therapists on the list of those who may be shareholders, officers, directors, or professional employees of medical, podiatric or chiropractic corporations.

In 2009, Assembly Bill (AB) 1152 was brought forward by the California Podiatric Medical Association to determine the legality of podiatrists owning a physical therapy practice.

They were later joined by the California Medical Association and California Chiropractic Association.

Assembly Bill 1152 would have amended Section 2406 of the Business and Professions Code and Section 13401.5 of the Corporations Code to add licensed physical therapists to the list of healing art practitioners who may be shareholders, officers, directors, or professional employees of medical, podiatric or chiropractic corporations.

CPTA strongly opposed AB 1152 because the legislation would have made it legal for medical, podiatric and chiropractic corporations to employ physical therapists.

In effect, under this legislation, these corporations could control the point of access to physical therapist services and then refer patients only to themselves.

This type of arrangement poses an inherent conflict of interest and removes choice for the consumer.

On July 13, 2009 the members of the Senate Business Professions and Economic Development Committee understood the potential conflict and did not pass the bill.

The opinion from Legislative Counsel confirms that, because the California Corporations Code does not specifically include physical therapists on the list of those who may be employed by a medical corporation, a physical therapist is prohibited from providing physical therapy services as an employee of a medical corporation and may be subject to discipline by the Physical Therapy Board of California for doing so."
According to the California Physical Therapists' Association (CPTA) employee physical therapists have three options:
  1. Buy out the practice
  2. Become an independent contractor
  3. Find new empoyment
The CPTA has laid out these options in the CPTA Employment Toolkit to help affected therapists transition to new business arrangements.

As an independent physical therapist involved in Government Affairs in Florida I watch events like the California decision with keen interest.

Is this way the right way?

Does the California decision improve their position compared to the position of physical therapists in South Carolina?

Is the California approach better than the approach taken in Washington state?

Monday, December 13, 2010

Dangers of NSAIDs - no side effects of physical therapy!

Thanks, ZDoggMD, for spreading the word on excessive NSAID use.

Here's the good doctor's entertaining and educational video:

Putting a human face on medicine, making people laugh and educating people is EXACTLY what doctors and physical therapists need to be doing!

Great work, ZDoggMD!

With Great Power Comes Great Responsibility

...these are the words of Dr. Donald M. Berwick, Administrator, Centers for Medicare and Medicaid Services on October 5th, 2010 as he was wrapping-up a workshop on Accountable Care Organizations in Baltimore.

Dr. Berwick was quoting Spiderman, trying to motivate and incentivize the gathered healthcare providers, attorneys, corporate executives and other stakeholders trying to figure out what the new rules of the game will be from the largest single purchaser of healthcare services in the world.

There is currently much interest among physical therapist private practices in the new Accountable Care Organizations that Dr. Berwick sees as new "...care delivery organizations, not as financing mechanism...".

Yet, there is little reassurance for private practitioners at the bottom of the referral nework that hospitals and large physician organizations will share the gains equitably if they become the "bankers" of the new ACO.

Ten years of research shows that physical therapy reduces costs and improves outcomes for high cost drivers like lower back pain.

Are there any assurances that physical therapists will become primary care providers for these patients? Won't hospitals have the incentive to under-treat these patients?

CMS is betting the farm on the cost-saving features of ACOs and counting on some, as yet undefined, quality measure to prevent undertreatment by hospitals.

Dr. Berwick finished up his speech by saying...
"Let me be clear, in closing, about one final, serious matter: authenticity.
Authenticity matters.
Those who wish only to preserve the status quo are not going to be constructive contributors to our nation’s future.
They cannot be effective partners, and we simply do not have time to pretend that they are.
We just do not have time for games anymore."
Tough talk - I like that - except that, when ACOs do arrive in two years, Spiderman won't be here to save us.

Thursday, December 9, 2010

Urologists Self Refer Cancer Patients and Drive up Medicare Costs

Physical therapists will be familiar with the downside of physician self referral since medical specialties which use lots of physical therapy started bringing therapy clinics in-house in 2006 when clarifications to the Stark 2 "In-Office Ancillary Services Exception" were published in the Federal Register.

Now its urologists turn to stand in the spotlight thanks to this Wall Street Journal article and video interview exposing these self-serving practices.

The article focuses on a $40,000 treatment known as Intensity Modulated Radiation Therapy (IMRT) which is an aggressive and expensive option for a disease that may not kill you until you're 120 years old.

Unfortunately, by then Medicare will be insolvent - perhaps due in part to the rapid rise in costs from IMRT treatments.

This video describes shows the sales pitch delivered by a company marketing the technology to urologists:

Dr. Gerald Chodak of Medscape speaks out against urologists' practice of self-referral.

I wonder why we don't see any orthopedists or neurosurgeons speaking out against self-referral?

Friday, December 3, 2010

Do Physicians Make Decisions Based on Financial Factors?

Dr. Gerald Chodak of Medscape questions that treatment decisions made by urologists who own the equipment and do intensity-modulated radiation therapy (IMRT) for localized prostate cancer may be influenced by financial factors.

Dr. Chodak says,
"For physicians who do radical prostatectomies, the net profit is between $2,000 and $3,000, depending on who is paying for it.

Active surveillance doesn't pay nearly as well."
Dr. Chodak recommends a "constant fee" - no matter how the patient is treated.

I wonder how a constant fee would work for physical therapists?

See the page and the doctor's comments at Medscape.com.

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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 .

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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.