"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

Wednesday, December 28, 2011

New Treatment Based Classification Chart with Hyperlinks

These are the Treatment Based Classification rules I've been using the past couple of years. Please use this chart, including the hyperlinks. Let me know if you see any ommissions or if you recommend a rule I have not included.

Rule Author Year Level of Rule Development
Cancer Rule in Lower Back Pain Patients Joines et al 2001 Cost Effectiveness study
Lumbar Manipulation Rule Flynn et al 2002 Broad Validation
Lumbar Stabilization Rule Hicks et al 2005 Derivation
Lumbar Traction Rule Fritz et al 2007 Expert Consensus
Thoracic Manipulation Rule for Neck Pain Cleland et al 2007 Broad Validation by Cleland in 2010 demonstrated NO rule is needed - ALL neck pain patients without "red flags" get manipulation
Ankle Mobilization for Inversion Injuries Whitman et al 2007 Derivation
Hip Manipulation Rule for Knee Pain Currier et al 2007 Derivation
Specific Directional Exercise for Lower Back Pain Browder et al 2007 Expert Consensus
Lumbopelvic Manipulation for Anterior Knee Pain Iverson et al 2008 Derivation
Cervical Traction Rule Raney et al 2009 Derivation
Thoracic Manipulation Rule for Shoulder Pain Mintken et al 2010 Derivation

This chart is regularly updated at www.BulletprootPT.com.

Why Do Physical Therapists Need to Track Florida's 2012 Legislative Bills?

I think it was Mark Twain who said:
"We should never watch laws or sausage being made, for if we did we would lose our appetite for both"

Yet I'm now going to suggest to you that you sign up for the Bill Tracker features on the Florida Senate and the Florida House websites.

These features will give you a blow-by-blow stream of e-mail messages on the progress or barriers to the 2012 Florida Physical Therapy Association's legislative bills.

Senate Bill 1128 by Senator Montford and House Bill 799 by Rep. Goodson will enact Temporary Licensure for Physical Therapists and Physical Therapist Assistants by making changes to the physical therapist practice act (FS 486).

So, why should you want to watch our legislation being made (hopefully) into a new law for the State of Florida?

Here are some suggested reasons to sign up for Bill Tracker:
  • You will stay current with the FPTA bill's progress or setbacks.
  • You will receive periodic updates
  • You will be able to mobilize your local Key Contacts should the bill get stuck in committee.
  • You will know at a moments notice if your presence is needed in Tallahassee for testimony before committee.

Here is a short video (1:41) showing the set-up process of the Florida Senate website

Its free. Its easy.

I just hope you don't lose your appetite for the legislative process.

Sunday, December 25, 2011

Support New York Physical Therapists' CoPayment Legislation

Physical therapists will again put CoPayment reform legislation before the New York legislature in 2012. Twice now the legislation has been put forward for consideration.

In 2011, CoPayment was advanced but not all the way to a vote in the legislature (in general, fewer than 10% of bills in ANY state each year are passed into law).

This article in the New York Daily News describes grassroots efforts to advance CoPayment in New York, once again.

Please comment.

Your comments in this newspapers' web site will influence the media perspective of physical therapist CoPayment legislation.

We want the media to know this is an important issue for patients, physical therapists and payers.

Physical therapists in New York NEED your comments!

Help the Physical Therapy Alliance of Upstate New York (PTAUNY) and the New York Physical Therapy Association push CoPayment legislation forward in the New York state legislature in 2012. 

Please comment on this newspaper story so it gets more media attention.

Thank you.

Friday, December 16, 2011

Healthcare CEOs Richest 1% in North America

Healthcare CEOs are the among the richest American executives across all industries.

Three of the top-earning 10 executives across all industries were in healthcare:
  • Healthcare company McKesson Corp. Chief Executive John Hammergren topped the list with nearly $145.3 million in compensation in 2010
  • Following McKesson is Omnicare's CEO in second place for the highest paid exec with $98.3 million
  • Former CEO of health insurance company Aetna Ronald Williams received a total of $57.8

"The survey, called the most extensive study of CEO pay in North America, demonstrates the widening gap between incomes, especially in light of protesters of Occupy Wall Street who call attention to "the 1 percent," reports The Guardian."
The salary survey was performed by research group GMI Ratings:
“The 36.5 percent increase in realized compensation is particularly notable when it’s put in context of the modest growth of the economy in 2010 and general public company performance last year,” said Paul Hodgson, Chief Communications Officer and Senior Research Associate at GMI"
In a time when workers, patients and private practice physical therapists are struggling the income granted to these individuals seems excessive.

Their claim to create "value" for all stakeholders, not just the chareholder, seems unfounded.

Who else thinks America's market-based system has come off the rails - at least in healthcare?

The advantage of capitalism over central planning is that it distributes resources MORE efficiently.

This story suggests that WINNER TAKE ALL is the new normal.


Distracted Doctoring Raises Risks For Patients

This free New York Times article discribes a disturbing trend for which peer-reviewed research is just beginning to emerge:
  • nurses and doctors gued to their iPads in the hospital
  • technicians who monitor bypass machines talking on cellphones during heart surgery
  • a neurosurgeon making personal calls during an operation
  • a nurse checking airfares during surgery
  • providers routinely texting during surgical or medical procedures

This January 2011 article in Perfusion describes cell phone use during heart bypass procedures.

Do physical therapists routinely use mobile devices, such as iPhones, in the clinic?

Does mobile device use in the ambulatory outpatient setting pose the risk to patient safety that the same behavior in surgical settings poses?

My assessment is no.

What do you think?

Please comment.

Sitting Disease Cured by Exercise!

Friday, December 9, 2011

Fair CoPayment Web Page Now Online at APTA

The new American Physical Therapy Assocation (APTA) Fair CoPayment web page went live on December 7th, 2011.

Physical therapists advocating for improved patient access at the state level should look at the resources available here to help your state association craft your legislative strategy.

It's exciting to see the momentum this issue is beginning to generate.

I'm curious to see which states in 2012 advance CoPayment legislation for consideration.

The Process of Profitability

Physical therapists can learn from this highly successful company. They sell 10% af all the furniture in the world, they made $30 BILLION in revenue in 2010 and their estimated profit margin is 10%.

This company has created a process for customers to buy their products, become loyal customers, leave their stores highly satisfied and eagerly look forward to coming back and spending more money.

The customer is encouraged to browse the store, selecting what they want to purchase while following a SPECIFIC PATHWAY.

Who is this company? Follow the arrows to find out.

The "process" is easy - this company paints arrows on the floor of their HUGE stores to help customers navigate through the thousands of products they offer.

Not every product is costly - you can spend as little as 50 cents on some items. You may also spend thousands of dollars in their store. The average customer spend $85 dollars per visit. A single trip to one of their stores may take 3-4 hours so the company has a full-service, sit-down gourmet restaurant for when you get hungry.

What does this company have to do with physical therapists? Physical therapists can learn from them how to make the process of physical therapy easier, more fun and more rewarding for our patients. And, not mention, more profitable for physical therapists.

The "process" of physical therapy is one of the quality measures defined by the National Quality Measures Clearinghouse (NQMC) of Clinical Quality Measures. The five domains are generally described as follows:
  • Process
  • Access 
  • Outcome 
  • Structure 
  • Patient Experience
The process-of-care is defined as a health care-related activity performed for, on behalf of, or by a patient.
"Process measures are supported by evidence that the clinical process—that is the focus of the measure—has led to improved outcomes. 
These measures are generally calculated using patients eligible for a particular service in the denominator, and the patients who either do or do not receive the service in the numerator. 
Example: The percentage of patients with chronic stable coronary artery disease (CAD) who were prescribed lipid-lowering therapy."

Physical therapy in the United States is unusual in that many of the processes we traditionally perform, such as the following:
  • Physician certification of the Plan of Care 
  • Written Progress Notes 
  • Discharge Summaries 
  • Episodic treatment for chronic conditions (eg: three time per week for 1 month) 
  • etcetera 
...are NOT supported by evidence that they lead to better outcomes, lower costs or a better patient experience.

Innovative physical therapists will need to find a way to get these Medicare-mandated processes performed while improving the patient experience.

Innovation is what drives this company. They are the global arbiters of style in home furnishing.

Additionally, they have discovered that customers don't really want furniture - we want a place to sleep, something to write on and something to sit on. The actual pieces of wood that this company sells are not the highest "quality" - as defined by contemporary standards of furniture quality.

But, customers buy them.

Who is this company?


What innovations can physical therapists propose, within the Medicare-mandated process-of-care, to improve the patient experience in the United States?

Please comment.

Tuesday, December 6, 2011

Hospitals Bounce Back but Florida Physical Therapists May Still Get the "Take Back Letter"

Florida physical therapsists may still be on the hook, beginning January 1, 2012, resulting in the dreaded "Take Back Letter" from Medicare for services provided to orthopedic patients who don't meet new Medical Necessity requirements under Recovery Audit Contractors (RAC).
"The physicians will receive a form letter which will be entitled a “Take-Back Letter” requiring return of any funds paid in conjunction with the affected hospitalization. 
This will affect all cardiologists and orthopedists involved in the care – both invasive and noninvasive.  
This may include outpatient reimbursement for follow-up care related to the hospitalization. It’s not clear whether other specialists or primary care physicians will also receive Take-Back Letters."

Peter R. Kovacek, PT, DPT, MSA of PT Manager reported Friday, December 3rd that Medicare was Tightening the Screws on high-utilization providers in high-utilization states, such as Florida, California, Michigan, Texas, New York, Louisiana, and Illinois.

The Financial Times, on Monday December 6th, reported that hospital operators, such as Tenet Healthcare, bounced back from the 11% share price drop on Friday:
"...but analysts remained concerned that government healthcare schemes may limit expensive cardiovascular and orthopedic treatments."
Physical therapists who treat post-surgical patients could see a drop in patient volume, beginning January 2012, from orthopedic surgeons.

Thursday, December 1, 2011

The Art and Science of Physical Therapy

The 2011 Oxford Debate at the APTA Annual Conference in Washington DC pitted clinical decision rules - algorithms - against clincial intuition. You can see some of the debaters coments here.

I wrote, at the time, that this was a false choice. Algorithms and intuition can BOTH be used by the physical therapist to improve patient outcomes and speed the clinical workflow.

It's not an either-or decision. The question is WHEN to use the algorithm and WHEN to use your intuition.

A recently published systematic review by Henschke to diagnose spinal fractures provides an example of HOW physical therapists can use algorithms and intuition together.

I included Henschke's original decision rule in my new book, Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting due out January 15th, 2012.

Henschke's new rule was also recently posted to PhysioPedia in a page titled Subjective Exam - Diagnostic Strength by Brian Duffy, Carleen Jogodka, Jeff Ryg, James White of the Evidence in Motion Fellowship program.

Henschke's New Rule to Diagnose Spinal Fractures

Henschke's rule to diagnose spinal fracture in a low risk setting provides physical therapists a unique opportunity to use their clinical intution.

Clinical Decision Rules are usually intended to provide probabilities confirming a diagnosis or predicting an outcome so the physical therapist can make clinical decisions with confidence.

Henschke's rule screens patients for vertebral fractures without the use of expensive and overly sensitive diagnostic imaging. This rule may be employed in two different settings: low risk primary care offices or high risk emergency rooms. The setting determines the pre-test probability, or prevalence.

Here is Henschke's new rule:
  • History of major trauma
  • Pain and tenderness
  • Age < 50 years
  • Female
  • Corticosteroid use
The base rate of vertebral fractures in a population of 1,172 patients accessing primary care for treatment of lower back pain in Sydney, Australia was 0.5%. Primary care in Australia is defined as offices of physicians, physical therapists and chiropractors.

Low Risk Decision Rule
Screening Finding PresentLikelihood of the Diagnosis
1 present1% chance of a spinal fracture
2 present7% chance of a spinal fracture
3 or more present52% chance of a spinal fracture

The base rate of vertebral fractures in patients accessing the emergency room and specialty physicians’ offices for treatment of lower back pain in Sydney, Australia was 3.0%.

High Risk Decision Rule
Screening Finding PresentLikelihood of the Diagnosis
1 present5% chance of a spinal fracture
2 present32% chance of a spinal fracture
3 or more present87% chance of a spinal fracture

The predictive power of the decision rule varies with the setting in which the clinician sees the patient – high risk patients seen in specialty clinics had a higher prevalence of spinal fracture. The new rule is the same in both settings.

The physical therapist's intuition is especially important in the LOW RISK situation when three or more of the subjective variables were present. In this situation, the clinical decision rule returns a probability of 52% favoring the diagnosis of vertebral fracture. The rule, in this situation, barely performs better than chance.

A physical therapist flipping a coin could do just as well in predicting a spinal fracture (~50%).

In this situation, the physical therapist should rely on their clinical intuition. Intuiton might include additional data points from the physical therapy evaluation, including:
  • the patient's history
  • subjective pain complaints
  • physical examination
  • special tests 
  • other pathology screening exams.

Also, a medication list, cognitive status and input from family members could add useful data points that might increase or decrease the probability of a fracture.

This example is meant to demonstrate WHY physical therapist intuition is still important, combined with first-pass screening algorithms that supplement human memory for low-frequency events. In these situations, the use of clinical intuition and experience supplements the algorithmic decision rule.

Henschke's rule to diagnose spinal fracture is a useful algorithm for screening high risk patients in the emergency room.

In the low risk setting, such as an ambulatory PT clinic, the rule requires that the physical therapist remain alert to subtle cues that might affect the diagnosis.

Henschke's rule demonstrates clearly how your diagnosis requires both the art and the science of physical therapy.

Wednesday, November 30, 2011

Primary Care Physicians Call for Exercises to Treat Lower Back Pain

Wiser words were never spoke in addressing the paradox of payment for lower back pain and physical therapy treatments. Read on...
"We physicians should refer our patients for exercise... 
...practitioners should work to standardize treatments...
...and payers should encourage these treatments through minimization of copayments for therapies that have both effectiveness and modest cost," 
...concludes a comparative effectiveness study on the benefits of yoga for chronic back pain.

 The study, published online October 24th, 2011 in the Archives of Internal Medicine found that yoga and stretching exercises were superior to education provided by a primary care physician along with a self-care book.

The outcome measure used in the Archives study was the Roland-Morris Disability Questionnaire (RDQ).

A seperate study in the Annals of Internal Medicine, published in November 2011, found that functional scores improved with yoga but chronic lower back pain scores did not improve.

I would like to see this study repeated with physical therapists providing the stretching and/or the yoga treatments.

Rather than studying the comparative effectiveness of branded treatments (eg: yoga) we should study the comparative effectiveness of branded professionals.

Tuesday, November 29, 2011

Name That Country Quiz!

Can you name this country?
  • Primary care physicians earn 20% more than specialty physicians in this country.
  • This country has highly coordinated care: specialty referrals are closely tracked by the referring PCP.
  • They have sophisticated electronic medical records.
  • They have high patient satisfaction.
  • They have low costs.
  • They have good patient outcomes.
  • They have 100% access to healthcare services by everyone.
What country are we describing? Find out here.

Monday, November 28, 2011

Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals?

Doom-and-gloom futurists project a "doctor shortage" in the United States but new studies increasingly support the roll of non-physician providers in primary care settings, such as hospitals.

A recent study in the December 2011 Health Services Research found that direct access to physical therapists is associated with lower costs and fewer visits and suggests that...
"...the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases."
Patient satisfaction is driven by clinicians who do the following:
  1. spend more time with patients
  2. listen more closely
  3. provide more feedback
  4. show more respect for patients' opinions
Time spent with the patient AND cultural competency were both factors in a small study presented in June 2011 at the American Academy of Nurse Practitioners (AANP) 26th Annual Meeting in Las Vegas.

The survey of just under 200 patients found that only 50% of physicians' patients reported that they felt that doctors "always" listened carefully, compared with more than 80% of nurse practicioners patients.

Physicial therapists are trained in listening to patients and in cultural competency. I would like to see this study repeated - comparing physical therapists' patients to physicians' patients.

The forces driving increased utilization of non-physician care givers are not just based on quality and licensure. Cost is also causing hospitals to consider nurses, physician assistants and physical therapists in primary care roles.

An October 2011 study in Nursing Economics examined nursing versus physician outcomes over an 18-year period and found the following:
"...patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included."
This Data Brief from the Centers for Disease Control and Prevention (CDC) shown that, despite regulatory and licensure barriers erected by state medical societies, hospitals are pushing the boundaries of non-physician scope of practice by hiring nurses and physician assistants for primary care roles at increasing rates.
"This analysis shows that visits to Physician Assistants (PA) or Advanced Practice Nurses (APN) have become more common in hospital outpatient departments over the past decade.

...Visits seen only by a PA or APN continue to be higher in rural areas. In addition, a higher proportion of visits to PAs or APNs occur with younger patients."
The American Physical Therapy Association (APTA) is examining ways that physical therapists can find opportunities in these primary care settings. Listen to this 11-minute podcast called Expectations of a Physical Therapist in the Emergency Department (member log-in required) to learn about expanded practice oppotunities.

The doom-and-gloom futurists have got it wrong, I think. There will not be a doctor shortage of the magnitude predicted. If anything, the shortage of physical therapists will only increase.

Now, how do we sqaure THAT circle for my private practice physical therapist brothers and sisters?

Wednesday, November 16, 2011

De-Skilled Physical Therapy?

De-skilling can occur to physicians who use Electronic Medical Records (EMR) and who follow Clinical Practice Guidelines (CPG). The de-skilling process includes the following:
  • decreased clinical knowledge
  • decreased patient trust
  • increased stereotyping of patients
  • decreased confidence in making clinical decisions.
These findings are not surprising to many clinicians who warn against losing the personal touch as clinics adopt EMRs.

Both physicians and physical therapists resent the tyranny of the computer screen that prevents them from spending face time with their patient while they enter quality measures.

These findings, presented in the October 2011 Health Care Management Review may be troubling to advocates of EMRs and Clinical Practice Guidelines.
"These deskilling dynamics are often presumed to be a byproduct of select managerial innovations designed to improve efficiency and lower cost, which force workers to perform their work in a more standardized, compartmentalized, and routine way."
My initial knee-jerk reaction to this article is to sympathize with clinicians, forced to work with first-generation EMR software and population-based practice guidelines that strictly limit individual preferences in clinical decision making.

But, the authors continue:
"It can be argued that professionals, like physicians, actively contribute to their own deskilling through how they adapt on an everyday basis...
  • to maintain job satisfaction
  • get needed work done in a timely manner
  • to show that they are performing appropriately
  • to survive economically
  • to keep control
  • to maintain order in their lives."
The main problem with EMRs and boilerplate treatment recommendation, such as we might get from Clinical Practice Guidelines, was the tendency of the 78 primary care physicians in the study to "cut-and-paste" patient data from one session to the next.
"The net result was that primary care doctors believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment."
According to these same doctors, this situation did not happen with paper records. That is because paper records forced doctors to dictate patient specific information into a patient’s record each session.

Physical therapist managers can help prevent the deskilling process from occurring by soliciting physical therapist input during their EMR implementation.

Physical therapist managers can preserve their clinicians ability to control their workflow and their ability to apply their professional expertise in desired ways.

Medicare Discusses New, Unpublished CERT Error Rates Affecting Physical Therapists in Florida

I just sat in on the quarterly Medicare First Coast Service Options (FCSO) Provider Outreach and Education Advisory Group, Part B (POE AG - B) conference call which revealed the newest, unpublished data on physical therapy practices in Florida.

The Medicare TOP PRIORITY for Florida is reducing their CERT error rate which at this time stands at an ALL TIME HIGH of 14.5%.

Most important, the number one cause of this high error rate is INSUFFICIENT DOCUMENTATION.

Specifically, 81% of the CERT error rate was due to one of the following:
  1. The written Plan of Care was not included
  2. The Progress Notes did not include reasons for continuing therapy.
  3. No daily treatment notes
  4. No physician certification of the Plan of Care

Physical therapists can improve their documentation using some simple tools:

Tuesday, November 15, 2011

Error Rate Among Medicare Auditors High

Recovery Audit Contractors (RAC) have recovered more dollars in 2011 than they did in 2010 but this metric of success may overstate their value.

A Washington Post story from yesterday, November 14 2011, shows that Medicare auditors make overpayment determinations based on "inaccurate data".

RAC activity in 2011 was centered in the West and the Southern United States.

Florida$7.1 million
California$7.7 million
Washington$5.3 million
Texas$5.8 million

"The error rate in the Medicare RAC process is disturbingly high, especially since the cost of filing an appeal can be prohibitive," said AMA President Peter W. Carmel, MD.

"The AMA is working with CMS to improve this process and decrease the financial and administrative burden on physicians."
A 2010 Office of the Inspector General (OIG) report found that CMS...
"...did not sufficiently oversee the RACs during the demonstration project to ensure the vulnerabilities pursued by RACs were valid and that RACs made accurate improper payment determinations.

According to provider associations, this led to numerous appeals of inaccurate RAC determinations that were expensive and burdensome for providers."
Physical therapists can reduce their risk of a RAC audit, or any Medicare audit by following the seven components of the OIG Compliance Program for Individual and Small Group Physician Practices.

Also, join the email tutorial in the sign-in boxes above or below this post.

Monday, November 14, 2011

Medicare Uses "Inaccurate and Inconsistent Data" to Audit Providers

The Washington Post reported today that...
"Medicare contractors are paid tens of millions of taxpayer dollars to detect fraudulent Medicare claims are using inaccurate and inconsistent data..."
The Washington Post is reporting on an unreleased report by the Office of the Inspector General (OIG)...
"The U.S. Department of Health and Human Services inspector general’s report — obtained by The Associated Press before its official release — found repeated problems among the fraud contractors over a decade and systemic failures by federal health officials to adequately supervise them."
The Recovery Audit Contractors (RAC) auditors were implemented in 2007 in Florida, California and Texas to solve these problems.
"CMS has repeatedly said the latest system of fraud contractors was designed to fix the problems with earlier contractors and allow the agency to better monitor them."
These RAC auditors are currently auditing physical therapists, physicians and hospitals.
"The same issues were identified 10 years ago by inspector general investigators, and dozens of reports in the past decade also have found problems.
In 2001, acting Inspector General Michael Mangano testified that the Centers for Medicare Medicaid Services (CMS) wasn’t doing a good job of holding contractors accountable."
I hope someone is auditing the auditors.

Sunday, November 13, 2011

Ten Commandments for Effective Decision Support in Physical Therapy

  1. Speed is Everything
  2. Anticipate the Physical Therapist's Need and Deliver Them In Real Time 
  3. Fit the Technology into the Physical Therapist's Workflow
  4. Little Things Make a Big Difference
  5. Recognize that Physical Therapists will Strongly Resist Stopping the Treatment
  6. Changing Directions is Easier Than Stopping
  7. Simple Interventions Work Best
  8. Ask For Additional Information from the Physical Therapist ONLY When You Need It
  9. Monitor Impact, Get Feedback and Respond
  10. Manage and Maintain Clinical Decision Support Systems for Physical Therapists
These commandments were originally written by Dr. David Bates in 2003 in anticipation of the electronic medical records revolution physical therapists and physicians are witnessing now.

They are surely as true now as they were then.

I would humbly suggest one additional commandment to add, in light of the recent, massive failure of the British centralized database of electronic medical records:
  1. Empower LOCAL decision makers (eg: physical therapists) to add to, delete or modify the decision support rules and allow interoperable CDS systems to "learn" from each other.
Right now, the ONLY CDS system that applies to physical therapists is a top-down government-mandated program that is, for the most part, paper-based.

I think we can do better.

What do you think?

Please comment.

Friday, November 11, 2011

High Cost Hospitals Realize That "The Jig Is Up..."

Over at the Health Care Blog, some physical therapists might find this dialogue interesting.

It's between a large hospital Chief Operating Officer (COO) and an independent Health Information Technology (HIT) consultant...
Consultant: "Why on earth would you want to form a Medicare Accountable Care Organization (ACO)?

You’re a monopoly. You’re making tons of money. You can keep doing this for some period of time."
Hospital COO: “Look I understand that the jig is up (since healthcare reform passed). 
I know how to take $60 (of costs) out per member per month. $60 - - out of my cost structure. I know exactly how to do it. 
I never had a motivation to do it before - - until health care reform happened."
Who else believes that physical therapists can take additional costs out of high-cost hospitals as we replace physicians using rules-based decision algorithms to make diagnoses and order x-rays and magnetic resonance imaging (MRI)?

Please comment and let's hear your thoughts.

Wednesday, November 9, 2011

Medicare Spending Flattens in 2011

2011 has been, so far, a good year for budget hawks.

A new report by the Congressional Budget Office (CBO) found that Medicare spending has flattened its steep climb, down from about 6% in 2010 to about 3% in 2011. The five-year average increase in Medicare spending has been about 7%, from 2006 - 2011.
"Outlays for the three largest entitlement programs— Social Security, Medicare, and Medicaid—rose by just over 3 percent in 2011, after an adjustment for payment shifts.
That increase was well below the growth of 6 percent recorded in 2010 and the roughly 7 percent average annual growth over the past five years—partly because previously legislated increases in the federal share of Medicaid’s costs expired; for the second year in a row, there was no cost-of-living adjustment for Social Security beneficiaries.
Outlays for the three programs equaled 9.8 percent of GDP, about the same as in 2010."
Why Should Physical Therapists Care About Out-of-Control Medicare Spending?

Aside from our dual role as American taxpayers, rapidly increasing Medicare spending strains the ability of Medicare to remain solvent.

Budget hawks are people who believe that smaller government budgets automatically improve everybody's economic well-being. Therefore, right now, many in the Congress are trying to implement across-the-board cuts to Medicare.

Recent evidence from the Urban Institute indicates that across-the-board cuts will lead to poorer health outcomes for some Medicare beneficiaries.

The flattened spending curve in 2011 may remove some of the pressure for across-the-board Medicare cuts in 2012.

Tuesday, November 8, 2011

Good Timing: November JOSPT and the October Archives of Internal Medicine

The Top Five overused clinical activities published in the October 2011 Archives of Internal Medicine includes at least one activity that affects many physical therapists' patients: imaging for lower back pain.

Overused Clinical ActivityRankCost to American Patients (in millions of dollars)
Expensive Brand Name Statins for Hypercholesterolemia1$5,800
Dual X-ray (DEXA) bone scans for Osteoporosis2$527
ANY imaging for Lower Back Pain3$175
Antibiotics for Children with Viral Colds4$116
Pap Tests for Patients Under 21 years of age5$47

The "Top Five" collectively surpass $6 billion dollars in wasted healthcare dollars and, according to the study authors, the Good Stewardship Working Group of primary care physicians...
"All activities were believed to be common in primary care but of little benefit to patients."
This Archives article coincides nicely with the November Journal of Orthopedic and Sports Physical Therapists (JOSPT) in which Flynn, Smith and Chou discuss the Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good.

Not only is imaging lower back pain expensive, but the patient ends up more likely to have back surgery after physicians view the image.

Further, the visualization by the patient of something "wrong" in their spine leads to avoidance of normal, healthy activity.

If the coincident publication of these two articles wasn't planned then I guess it's just good timing.

Friday, November 4, 2011

Health Lobbyists Seek Political Advantage with Supercommittee

Health care lobbyists make up the biggest spenders among organizations trying to gain political influence on the Joint Select Committee on Deficit Reduction, aka: the Supercommittee.

About 30 percent of these organizations, 118 groups in total, were from the health sector, according to the Center for Responsive Politics.

Among these 118 organizations were deep-pocketed groups such as the American Medical Association, the American Hospital Association and the Pharmaceutical Research and Manufacturers of America.

The American Physical Therapy Association (APTA) is also lobbying the Supercommittee to prevent cuts to Medicare.

Some groups, such as the American Osteopathic Association, have taken straight to the airwaves and the internet with informational and rhetorical appeals, in addition to lobbying their members of the Congress.

This chart shows where the oft-quoted "$300 billion" cost estimate to repeal the Medicare Sustainable Growth Rate (SGR) comes from. This estimate is also quoted as a savings estimate, if you're credulous enough to believe Washington budget math.

Some commentators believe that NO decision by the Supercommittee, and the attendant, automatic 2% across-the-board Medicare cut, is better than their "Go Big" scenario that may leave certain sectors within Medicare, such as Rehabilitation, financially devastated.

Members from both houses of the Congress wish for Supercommittee success but are vague of how to achieve that success, especially in regards to Medicare cuts:
"Similarly (they) did not give specific prescriptions on how to come up with major savings from programs like Medicare and Medicaid."
What do you think?

Please leave your comments.

Sunday, October 30, 2011

Does "Defensive Medicine" Drive Up Health Care Costs?


Not according to this report from PublicCitizen.org, A Failed Experiment: Health Care in Texas Has Worsened Since Medical Liability Caps in 2003.
"Those who blame medical malpractice litigation for rising health care costs and diminished access to care tend to focus on the theory that the fear of litigation motivates doctors to prescribe unnecessary tests and procedures to insulate themselves against potential lawsuits.
This is the crux of the defensive medicine argument.
Because Medicare Part B spending is sensitive to the volume of services, a jurisdiction experiencing a dramatic decrease in litigation should realize a decline in the rate of growth in Medicare Part B spending—or even an outright decline in such spending—if the defensive medicine argument is accurate.
According to the theory, the reduced litigation should have reduced doctors’ fear of being sued, which in turn should have reduced the number of tests and procedures doctors prescribed."
Here's the key data:
  • Medicare spending in Texas has risen far faster than the national average. Per enrollee spending for Medicare’s two main programs ranked second-highest in Texas among the 50 states in 2009. In 2003, Texas ranked seventh. In light of the steep reduction in litigation that has occurred in Texas since 2003, these figures contradict the theory that medical malpractice litigation is driving health care costs.
  • Medicare spending specifically for outpatient services in Texas has risen even more steeply compared to national averages.
  • Premiums for private health insurance in Texas have risen faster than the national average.
  • The percentage of Texans who lack health insurance has risen, solidifying the state’s dubious distinction of having the highest uninsured rate in the country.
  • The per capita increase in the number of doctors practicing in Texas has been far slower than in the preceding years.
  • The per capita number of primary care physicians practicing in Texas has remained flat, compared to a sharp increase in the years leading up to the caps.
  • The slope of the red line shows a 24% increase in physicians in rural areas, the green line shows a 1% DECREASE.

  • The prevalence of physicians in non-metropolitan areas has declined.

Why Should Physical Therapists Care About Defensive Medicine?
To the extent that physical therapists are leaders in reforming health care, we should resist "band aid" explanations and "simple" solutions about how to "fix" health care.

Medical liability reform will not "fix" defensive medicine, as the Texas experiment proves.

Real solutions to systemic problems of cost inflation and patient access will require a willingness to examine flawed assumptions that form the foundation of our medical care delivery network.

The main assumption we should examine is the idea that the existing medical hierarchy that puts physicians and other autonomous practitioners at the "sharp end" of health care is tenable and sustainable.

We blame errors and accidents on one individual instead of trying to design better systems that can anticipate and prevent errors in the first place.

How should we make a better system? What role should physical therapists play in the reformed health care system? We welcome your comments.

Saturday, October 29, 2011

POPTs Supporter Caught Shoplifting

Ethically challenged California Assemblywoman Mary Hayashi (D - Hayward) was arrested and bailed out of jail Thursday, October 27th on charges of felony grand theft.

Here is the full story in the San Francisco Chronicle.

Disgraced California Politican Mary Hayashi Before Her Shoplifting Arrest

Mary Hayashi attracted attention of physical therapists nationwide in 2009 when she attempted to pass pro-POPTs legislation in California making employment of physical therapists legal.

Currently in California, physical therapists are NOT legally employable by physicians but an injunction by the California Medical Association, brought by Hayashi in Summer 2011, prevents this law from being enforced until 2013.

Watch her Twitter stream to see reactions from physical therapists nationwide.

Thanks to Robert M. Bacci, PT, DPT of Bacci & Glinn Physical Therapy Inc.

Monday, October 24, 2011

How Clinical Decision Support Can Help Physical Therapists

It is a forgone conclusion that some sort of decision support technology will become a part of the daily workflow of the American physical therapist within the next 2-5 years.

What is not concluded are several things:
  • What will the user interface look like?
  • What decision rules will the software contain?
  • Will the Clinical Decision Support (CDS) be electronic or paper-based?
  • Will the decision rules be determined by a "top down mandate"?
  • What level of local control by the physical therapist will be allowed?
  • Will the hardware be a handheld tablet or desktop?
Clinical Decision Support tools are electronic tools that link at least two pieces of patient data to a knowledge base that provides a suggestion, a reminder, a prompt or an alert. CDS tools can be electronic or paper-based. The intended purpose of CDS tools is to make medicine more safe.

An example of a decision support tool might be the Physician Quality Reporting System measure for Falls Risk:
"If a patient is 65 years or older, screen for elevated falls risk using a history of a fall within the last year".
This is called the decision "trigger".

If the patient answers "Yes" to the therapist's query they are allocated to a "high risk" group for whom a falls intervention program is medically necessary.

If the patient answers "No" to the therapist's query they are allocated to a "low risk" group for whom falls intervention is NOT medically necessary.
This is called the decision "rule".

Clinical Decision Rules are one type of decision support that currently exists in medicine. Critical pathways are another type of decision support.

Critical pathways are a "top down" management style that work well in large institutions. The well-known Virginia Mason/Aetna Lower Back Pain is a successful example of a critical pathway from the standpoint of the physical therapist, the patient and the payer. Hospitals and sub-specialty physicians don't view the Virginia Mason critical pathway with great enthusiasm.

The Virginia Mason model was recently cited in Health Affairs journal as a "high value" model for institutional healthcare in America.

You can also read this blog post at the Evidence in Motion blog with comments by other physical therapists.

However, about 70% of healthcare in America is consumed in small, outpatient practices where critical pathways and top-down management styles may not work well.

Great Britian's recent failure of their centralized electronic health database was blamed on the heavy-handed, top-down imposition of health information technology on physicians. The physicians were not consulted prior to the mandate to get their input as to the best way to implement the mandate.

Commercial EMR vendors may be expected to be responsive to local physical therapists in designing the format and content of decision support tools. At this time however, only a few commercial clinical decision support systems exist in the physical therapy space.

Almost all of the commercial physical therapy-specific Electronic Medical Records contain prompts and reminders. These prompts and reminders, with the possible exception of a PQRS module, are designed not for patient safety but are designed to drive revenue maximization, code capture and Medicare compliance.

However, PQRS is the prototypical top-down decision support technology.

Clinical physical therapists should control their local technology, their own production and the work processes that produce their outcomes.

What sorts of improvements would readers of this blog recommend for a locally-determined CDS system to replace PQRS?

Sunday, October 23, 2011

British EMR Failure Invites Comparisons to USA HITECH Program

American physical therapists may breathe a sigh of relief that the Office of the National Coordinator of Health Information Technology (ONC HIT) will be less likely now to impose "top down" mandates for the purchase and use of interoperable health information technology now that Great Britain has decided to dismantle their failed system.

On September 22, 2011, the National Health Service (NHS) issued a Press Release announced that it was discontinuing its 10-year, $18.5 billion dollar effort to collect, computerize and centralize all of its electronic medical records. Existing electronic systems in hospitals and clinics would continue to operate but would not be interoperable across all of England.

The announcement essentially killed what had been hailed as “the world’s biggest civil information technology program” at that time.

The NHS program began in 2002 and was described as “top-down engineering” that met substantial resistance from physicians and other users of the system. The Press Release announcing the end of the program cited the lack of local control as the prime reason for the failure of its interoperable system:
“In a modernised NHS, which puts patients and clinicians in the driving seat for achieving health outcomes amongst the best in the world, it is no longer appropriate for a centralised authority to make decisions on behalf of local organisations.”
Authorities in the United States were quick to assure providers that a similar information technology (IT) effort stimulated by Title XIII of the American Recovery and Reinvestment Act of 2009, called the Health Information Technology for Economic and Clinical Health Act (HITECH) would not fail.

Faith in American electronic medical records is largely voiced by policymakers who say they are collaborating with providers, such as hospitals and physicians, rather than mandating a top-down structure.

Authorities claim that Electronic Medical Records strategy, standards and outcomes are set by HITECH Meaningful Use criteria but implementation is being set at the local level by any of the 900 certified IT vendors that the providers may choose to use. However, providers complains that 900 choices is NO better than no choice at all.

Why should private practice physical therapists care?

Used to be, we could just hang a shingle, treat your patients and expect to make a decent living. Now, if you want to work for yourself and your patients, you need to comply with all sorts of regulations that may or may not improve your patient care or add to your patient's outcomes.

For example, the Physican Quality Reporting System (PQRS) is a quality measure reporting program that has, since 2007, paid physical therapists up to 2% extra for treating and reporting Medicare claims data. In 2014, this little "extra" will turn into a discount and the program will turn into a top down mandate.

Can authorities in the USA learn from the British disaster?

I hope that authorities will learn that physical therapists, acting at the local level can determine what is quality and that some of these local measures can be used in place of centrally-determined, top down quality mandates.

Monday, October 17, 2011

"Safe" Legislation in Florida in 2012

There were, from my perspective, three "big" issues discussed by the physical therapy community at the American Physical Therapy Association's 2011 State Policy and Payment Forum in Austin, Texas:

  • Co-payment legislation (Kentucky, New York, New Jersey)
  • Direct Access legislation (Texas)
  • Anti-POPTs legislation (California)

Each of these states successfully implemented legislation that improves access for patients to physical therapists and physical therapist assistants. Each of these state had a unique story and a strategy for accomplishing their mission. Each state was able to accomplish their mission through a sustained grassroots movement and by substantial financial support from the membership, both within the state and from members in other states.

Web-based advocacy, fundraising, consciousness-raising, public relations, social media and communications were a significant factor in California, Texas and New Yorks’ legislative strategies.

Each of these states’ legislative strategies (which were all successful, by various measures) met with significant opposition from physician groups. The California opposition was particularly vociferous, even resorting to name-calling and punitive actions.

There was also a very important piece of research presented in Austin by Pendergrass et al that showed self-referred PT episodes used 14% fewer visits and cost 13% less than physician directed episodes of care. I mention this because it is a landmark study but I view this within the context of Direct Access legislation.

I provide extensive details in these blog posts, written during the presentations and the breakout sessions. Since this is a summary document, I will just provide the links:

How should the physical therapist community respond to this new information?

Each state must make its own choice based on its members’ needs, available resources and unique legislative situation. Before embarking on any course of action, it is essential that a plurality of the membership support the decision.

From my perspective, there are two general approaches state leadership could choose:
  1. The “safe” alternative as proposed by Florida
  2. A more controversial alternative, such as pursued by California and Texas.
Two of my assumptions should be made clear here:
  1. Most states desire a broad-based “grassroots” support from their PT and PTA membership both to assure that the collective needs are being addressed and to distribute the workload on moving forward a legislative agenda.
  2. Most states desire and need ongoing, substantial financial donations to the physical therapist Political Action Committee (PAC) to support lobbying efforts.
I define “successful” legislation as having met these goals, rather than mere passage by the state legislature.

To illustrate one course of action, I will describe the choice made by Florida (3rd largest state by population) and contrast that with the choices made by California (1st largest state) in choosing a legislative strategy.

Immediately following the 2011 State Policy and Payment Forum, to which Florida sent two representatives, the Florida leadership elected to pursue a “safe” legislative agenda in 2012. This agenda will attempt to open the Florida Practice Act (FS 486) to improve language offering Temporary Licenses to new graduate PT and PTAs.

The Florida Physical Therapy Association (FPTA) lobbyists feel that Temporary License legislation is unlikely to be opposed by physician or specialty groups seeking to defend their turf. Therefore, in their opinion, Temporary License legislation is “safe”. It seems unlikely that Temporary License legislation, however worthy it is on its own merits, will deliver that same benefits gained by California, Texas and Kentucky.

Evidence offered by California and Texas showed that Anti-POPTs and Direct Access legislation, respectively, earned ADDITIONAL donations to the state PAC of $100,000 and $60,000, respectively. Also, California gained over 3,000 signatures on a petition supporting anti-POPTs legislation. Over 400 Texas physical came to San Antonio in 2011 to rally in support of Direct Access legislation. California enjoyed extensive and favorable nationally syndicated television and print media exposure in support of their anti-POPTs effort.

In both California and Texas, their respective legislative efforts were anything but “safe”.

I provide additional supporting documentation on “safe” legislation in a previous post.

State leadership needs to understand the risk/reward exchange they face each year among competing legislative priorities and rank the various issues that could be (and have been) addressed through legislative means and assign an explicit risk, dichotomized as high/low, and an explicit reward.

That way, individual leaders from each state could use the document to better understand the rewards they might expect from a well-planned “controversial” legislative strategy. Also, they might better understand the risks they face from so-called “safe” legislation.

Like hiding your money in your mattress to make sure that it is “safe”, failing to pursue an aggressive legislative agenda in this era of health care change just might prevent physical therapists from reaching our goals.

Friday, September 30, 2011

Ready, Fire, Aim: The Case for CoPayment Legislation in Florida in 2012


Florida needs passion in 2012.
  • Without passion we will not have legislative success.
  • Without passion, we will not have increased grassroots support.
  • Without passion, we will not have more donations to our Political Action Committee.
The three "hot topics" from the Austin, Texas APTA State Payment and Policy Forum on September 23-26, 2011 were these:
  1. Direct Access (Texas)
  2. POPTs (California)
  3. Co-payment legislation (Kentucky, New York and New Jersey) 
Texas raised $60,000 over-and-above it's typical level of PAC donations for its Direct Access PAC in a highly public and highly controversial legislative session packed with hot button issues crowding the media:
  • illegal immigration
  • concealed carry permits for Glocks on college campuses
  • innoculating 6th grade girls with HPV vaccine
The Texas Physical Therapy Association (TPTA) rose above these emotional issues with a carefully orchestrated public relations campaign that emphasized the Texas consumer.

The TPTA also excited over 500 physical therapists and physical therapist assistants to travel to the Texas capitol for Rally Day in support of Direct Access legislation.

Incidentally, Texas also excited the mainstream media (television) to broadcast news stories about direct access to physical therapists.

California lit up the physical therapy blogosphere in 2011.

California also lit up the print media in Los Angeles and, according to Paul Gaspar DPT, legislators' colorful language lit up the California capitol, Sacremento. (Incidentally, the original, Spanish name for Sacremento was "Sacred Mind". I wonder how sacred was the legislators' language? :)

California raised over $100,000 in direct POPTs PAC support from AROUND THE NATION. Not just California. That's passion.

Not only did California excite the nation, generate passion from physical therapists and raise buckets of money but THEY ALSO WON! POPTs are now illegal in California.

Now, California physical therapists just need enforcement of the new, anti-POPTs legislation.

Kentucky was a slam dunk! The Kentucky House voted 98-to-zero to approve physical therapy co-payment legislation.

Dave Pariser, PT, PhD was partying hard in New Orleans in February 2011 and he had to come home when he heard that a groundswell of public and legislative opinion had arisen in favor of CoPay.

Dave had to come home to shepherd SB 112 through the Senate. It squeaked through, 30-to-6, in favor. Thanks, Dave and to the KPTA.

The actuality was that the KPTA had NO INTENTION of Kentucky CoPay legislation winning ANY support in 2011. But, it did. Why? Passion.

This time the passion was from the Kentucky consumers. They wanted relief. They wanted relief from the gradual shift that insurance companies and employers had placed on employees' copays.

Kentucky voters wanted Co-payment legislation in 2011.

Florida needs passion in 2012.

The stated intent of the Florida Physical Therapy Association, from the FPTA Assembly on September 24th, 2011, is to move forward with Temporary Licensure for Physical Therapy Students. While Temporary Licensure is important, its definitely not passionate.

Without passion, the Florida Physical Therapy Association (FPTA) will get nowhere in 2012.

Temporary Licensure will not be effective in 2012 for the following reasons:
  • Student don't have money to donate to the FPTA PAC for Temporary Licensure .
  • No one else is going to donate to the PAC (above 2011 levels) for issues that they're not passionate about.
  • Controversy is necessary to raise physical therapists above the media fray - don't be afraid of controversy.
  • Controversy sells - PAC donations are driven by emotion, not logic.
  • Grassroots support will arise when physical therapists appeal to the consumer/patient
My pick for Florida in 2012 on a platform of Temporary License legislation:
  • Flat to negative Political Action Committee (PAC) donations over 2011
  • No rally in Tallahassee with 250 therapists supporting Temporary License legislation
  • No grassroots support for Temporary License legislation
  • Odds of successful passage of Temporary License legislation, 3-to-1 against, that is, 25% chance of passage.

Tuesday, September 27, 2011

Columbia U, Duke U and Washington U Students Can Make the Physical Therapists' Diagnosis

Direct Access to Physical Therapists has been in effect in the United States since the 1950's and NO state direct access law has EVER been overturned.

Watch the entire video. 13:01min.

Thanks to Ryan J. Grella, PT, DPT, OCS and Adam Geril, DPT at Medical Business Leaders Network

Sunday, September 25, 2011

The Kentucky Blueprint for Legislative Success

Building on the 2011 successful Kentucky Physical Therapy Association (KPTA) copayment legislation, Dave Pariser, PT, PhD KPTA Legislative Chair and Leigh Ann Thacker, Chapter Lobbyist gave a breakout demonstration at the American Physical Therapy Association (APTA) State Payment and Policy Forum in Austin, Texas on the process physical therapists can follow to successfully implement co-payment legislation in your state.

Here is the actual bill language that KPTA passed in the Kentucky Senate.
  1. An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by an occupational therapist licensed under KRS Chapter 319A or a physical therapist licensed under KRS Chapter 327 that is greater than the copayment or coinsurance amount charged to the insured for the services of a physician or an osteopath licensed under KRS Chapter 311 for an office visit.
  2. An insurer shall state clearly the availability of occupational and physical therapy coverage under its plan and all related limitations, conditions, and exclusions.
Here is how the actual vote went down in Kenucky:

Feb. 23, 2011Kentucky Senate306
March 13,2011Kentucky House980

However, when you go to implement YOUR state physical therapy copayment bill the KPTA recommends this ideal language for your state's legislation: 

  1. An insurer shall not impose a copayment, coinsurance OR DEDUCTIBLE amount charged to the insured for services rendered for each date of service by an occupational therapist licensed under KRS Chapter 319A or a physical therapist licensed under KRS Chapter 327 that is greater than the copayment or coinsurance amount charged to the insured for the services of a PRIMARY CARE physician or an osteopath licensed under KRS Chapter 311 for an office visit.
  2. An insurer shall state clearly the availability of occupational and physical therapy coverage under its plan and all related limitations, conditions, and exclusions.
Physical therapists can help move their copayment legislation forward by doing the following:
  • Survey your state membership FIRST to see if MOST of the membership perceive copayment legislation important enough to get behind - believe it or not you may encounter opposition, either overt or covert.
  • Collecting copayment information for your patients' PT, MD and medical sub-specialty co-payments.
  • Collecting insurance company remisions, especially those amounts that are for $1 or $2.
  • Talking to patients and collecting stories about patient hardships related to difficulty accessing necessary physical therapy services due to high co-pays.
  • Talking to friends and neighbors about hardships related to difficulty accessing necessary physical therapy services due to high co-pays.

Physicians Cannot Control Physical Therapy Costs Under Medicare ACOs

Physician directed care cannot control costs under Medicare Accountable Care Organizations - that is the conclusion of a new report by Dr. Jane Pendergrast and presented by Dr. Pamela Duffy at the American Physical Therapy Association's State Payment and Policy Forum in Austin, Texas:
A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy
The professional best able to control costs for physical therapy services is likely the physical therapist, in collaboration with the patient.

Physical therapists can, and should, use this report to advocate for direct access by educating their payers and their state legislators.

Saturday, September 24, 2011

Are Physical Therapists Too Passive?

I heard the finest characterization of the political physical therapist from Juliana Koob, Legislative Advocate for the New Mexico chapter of the American Physical Therapy Association at the State Payment and Policy Forum in Austin, Texas today. Ms. Koob said:
"Physical therapists have the best work-life balance of all of my clients. They love their work but they generally love their private lives, too."
That's why grassroots action by state-level physical therapists often seems like all the work gets done by the same small group of people.

My conversation with Ms. Koob took place within the context of CEO Paul Hardin's discussion of the Texas Physical Therapy Association's (TPTA) attempt to secure physical therapy direct access legislation in 2011.

The Texas attempt enjoyed a broad support from leaders in the Texas private practice setting, a sophisticated social media campaign and grassroots activity from all over Texas and, perhaps, the United States.

The initiative for the Texas Direct Access legislation and much of the heavy lifting to ensure it's passage (it missed by only one vote!) was probably done, in my opinion, by three people:
  • Cynthia Fisher, PT, DPT, MS, PCS President of the TPTA 
  • Paul Hardin, CEO of the TPTA and 
  • Eric Wilson, PT Legislative Chair of the TPTA

I don't want to take away recognition of the effort of the 500 physical therapist who showed up on Legislative Day in Austin, Texas or of the genuine grassroots support as evidenced by the 2,906 people who signed the petition supporting direct access to physical therapists.

I also don't discount the people who donated over $60,000 to the Texas Political Action Committee in support of Direct Access.

Physical therapists have great jobs with huge potential to impact peoples' lives. When we support and initiate political action to improve our impact we have to spend our private time - the situation that Ms. Koob observed.

But, that private time can be spent in fulfilling advocacy activities that add balance to your life by improving your patients' access to physical therapy.

According to Ms. Koob, politics doesn't have to be negative or contentious. Done correctly, politics may be just about talking one-on-one with your friends and neighbors.

Physical therapists are not passive. But, we may need to shed our idea that seeking influence in politics doesn't square with our image of a happy work-life balance.

For more updates from the APTA State Payment and Policy Forum in Austin, Texas follow the Twitter feed at @APTAadvocacy.

State Payment and Policy Forum in Austin, Texas

The mainstream media would have you believe that Federal legislation has a greater impact on your practice than state law.

Notwithstanding the 2009 Patient Protection and Affordable Care Act (PPACA) in most years Federal law tends not to change much.

But, state law is much more volatile. Most laws that affect your daily practice are made at the state level.

That's why I'm posting from the American Physical Therapy Association's (APTA) State Policy and Payment Forum in Austin, Texas. I'm here representing the Orthopedic Section of the APTA.

APTA members from around the nation will be discussing the following:
  • Direct Access to Physical Therapists 
  • Health Care Reform 
  • Medicare Accountable Care Organizations (ACOs) 
  • Physical Therapist Co-payment legislation 
  • Physician Owned Physical Therapy clinics (POPTs)

Omni Hotel Downtown Austin

Follow events like this Forum at APTA's Moving Forward blog as well as my Twitter feed.

Friday, September 23, 2011

Yeah, There's A Code For That

These videos are for any physical therapist who has ever smacked their forehead in amazement at the incredible complexity, micromanagement and incoherence of our centrally-planned medical non-system in the United States. Enjoy.

Code Z72.820 Sleep Deprivation

Code V91.07xA Burn Due to Jet Ski on Fire

Code w22.02xA Walked into a Lamp Post

Thanks to Paul Martin, PT at Paul Martin's View

Tuesday, September 20, 2011

Physical Therapist Innovators Can Impact Population Health

My post yesterday had a fascinating video from TED about the origin of new ideas.

Ideas are often thought of as "Eureka!" moments but Steven Johnson describes a "network" of ideas that are resident within a group of like minded-individuals that "fade into view" over time until the value of the idea becomes evident to everyone paying attention. This "bubbling up" process is described as innovation but the innovative process depends on the network, not just the brilliance or the insight of one person.

One innovative approach to health that is becoming more and more obvious is the wellness approach to population health. Population health will be important to anyone trying to understand what the future of outpatient physical therapy practice will look like.

Engaging Populations Through Total Health Management from Healthways, Inc. describes some of the biggest cost drivers in treating chronic conditions, like painful musculoskeletal conditions. These drivers are patient self-reported measures like...
  • "Am I thriving in my current situation?"
  • "Am I struggling in my life to just get by?"
  • "Am I suffering in my life?"
People who were suffering spent 50% more on medical services than people who were thriving.

If physical therapists could identify "sufferers" early in the course of rehabilitation perhaps we could help direct appropriate care to alleviate their suffering.

Physical therapists are currently challenged to remain relevant in the changing US healthcare system and understanding how to impact population health seems important for our future.

Free Tutorial

Get free stuff at BulletproofPT.com

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.