"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, January 26, 2011

State of the Union: Healthcare Reform 2011

On Thursday, Jan 27, 4:30 PM Eastern, Medscape will participate in a roundtable discussion in our nation’s capital.

They will be bringing you the pressing questions about healthcare reform to the White House, and they're interested in hearing from you.

Visit Medscape.com to submit your question. Here is the text of my question:
"Evidence of overutilization of diagnostic imaging and specific surgeries implies that physicians and hospitals make treatment decisions based, at least partly, on financial gain.

Many of these physicians are paid based on the volume of care they provide.

In 2014, hospitals will begin organizing Medicare payments into fixed payment (capitated) Accountable Care Organizations (ACO) which will be directed by the same group of physicians and administrators.

What mechanism will compel this group to switch from the current volume-driven model to a quality model?

One proposal I would like to make is de-centralizing the decision making to appropriately trained providers, like nurses, physician assistants and physical therapists.

Most of these professionals are paid a salary.

A mix of incentive-based physicians and salary-based professionals acting as primary care providers could prevent overutilization but also guard against "stinting" on care under the fixed-payment ACO model.

Physical therapists are not currently included as eligible professionals under Medicare Accountable Care Organizations (ACO).

Physical Therapists are trained to manage high-resource use chronic patients that tend to use lots of healthcare (doctor visits, hospitalizations and surgeries).

Physical therapists can keep these people in their homes - the lowest cost setting in all of healthcare.

I recommend including physical therapists in Medicare ACOs and decentralizing the decision making away from the "status quo".

Thank you,

Tim Richardson, PT
Do you have a question?

What would you like to see changed?

What do you think of healthcare reform?

Now's your chance to participate.

Go get 'em!

How to Create a Physical Therapy Plan of Care

New graduates and experienced physical therapists may need to justify their plan of care - what decision process do physical therapists typically use to select interventions, frequency and duration?

How much better will the patient get?

How long will therapy take?

  1. Prediction Rules: Since 2002, physical therapists have had access to predictive rules that may aid decision making for treatment selection, outcome prediction and suggesting the frequency and duration of the plan of care.

    Flynn's manipulation rule was the first physical therapy specific rule to suggest that patients may be categorized according to the treatment most likely to benefit them.
    cited references

    Other, medically-oriented rules exist such as...
    • prediction of pneumonia
    • spinal fracture
    • ankle/foot and knee fracture
    • deep vein thrombosis
    • cervical radiculopathy
    • carpal tunnel syndrome and others.
    These rules are helpful for predicting a medical diagnosis but not so much for a physical therapy plan of care.

    Prediction rules are a "top-down" mode of evidence-based practice that challenge many talented clinicians who believe they can make safe and effective decisions without these rules.
  2. Historical Claims Data: Research Triangle International aggregated 100% of 2006 Medicare claims data into the top ten diagnosis codes used by physical therapists. Typically, the therapist will match the diagnosis reported by the physician on the referral.

    The physicians's diagnosis is a valid starting point for the physical therapists' diagnosis and one that is comfortable for many physical therapists still practicing within the medical model.

    Claims data reported to Medicare on the CMS 1500 (or UB92 for Part A settings) lists the ICD-9 code which should match the diagnosis supplied by the referring physician.Claims data are imprecise estimators of the patients' baseline level of function, discharge status and amount of clinical change. Unfortunately, these data are probably the largest data set publicly available to physical therapists in the United States.

    There may be some validity in using these data, imprecise as they are. James Surowiecki argues in the Wisdom of Crowds that "under the right circumstances, groups are remarkably intelligent, and are often smarter than the smartest people in them."

  3. Matching Your Patient to a Study Sample in a Randomized Controlled Trial (RCT): Buck and Ciccone demonstrate a "bottom-up" approach to ask a clinical question for a patient with intermittent claudication in Physical Therapy Journal in 2006.

    Physical therapists can ask a specific clinical question, conduct a keyword-based literature search, filter the retrieved articles and review the articles to see if the clinical question has been answered.

    Buck and Ciccone's bottom-up approach - contrasted with the "top-down" approach described above - may return a closely-matched study sample whose characteristics match a single patient.

    Best case would be a randomized controlled trial that shows the treatment applied to the study sample is superior to some alternative, like medication.

    For example, Deyle et al conducted a RCT on 83 patients with hip and knee arthritis comparing manual physical therapy to placebo. Average age was 60 years. Outcomes were a 6-minute timed walking tests and the WOMAC patient self-report scale. The placebo group received detuned ultrasound.

    Both groups were seen two times per week for four weeks. Outcomes measured at two weeks, eight weeks and 1-year showed "clinically and statistically significant gains over baseline WOMAC scores and walking distance".

    It seems reasonable to used studies like Deyle's to justify a plan of care for similar patients.

  4. Default to the Physician Prescription: Notice this is different #2 above where physical therapists merely use the physicians' diagnosis (eg: peripheral neuropathy) as a starting point in their decision making.

    One traditional role played by physical therapists (myself included) has been to accept the physician orders for therapy (eg: 3 times per week for 4 weeks) even for stable conditions, like peripheral neuropathy, that may need longer duration, intermittent frequency physical therapy.

    I would argue that Option #4, the default, does not justify our services in 2011 when other, better methods are available.

    What do you think?

Wednesday, January 19, 2011

Are Physical Therapists Waiting for Electronic Medical Records?

"It's not that we don't care, we just know that the fight ain't fair... so we keep on waiting - waiting on the world to change"
Get Where The Light Is: John Mayer Live In Los AngelesDVD.

Physical therapists aren't the only ones waiting... Physicians, too, have traditionally waited before purchasing an electronic medical record (EMR).

However, physical therapists can take heart that we are not too far behind the curve set by physicians in the United States.

Until recently, physician adoption of EMRs has been fairly slow. But, all that changed on February 17, 2009 when President Obama signed the The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to promote the adoption and meaningful use of health information technology.
"Pursuant to the HiTECH Act, providers can be eligible of incentives of up to $44,000."
Provider, however, is ONLY defined as physicians - not physical therapists...
  • Doctor of Medicine
  • Doctor of Osteopathy
  • Doctor of Podiatric Medicine
  • Doctor of Optometry
  • Doctor of Oral Surgery
  • Doctor of Dental Medicine
For the Medicare reimbursement of up to $44,000, the term eligible professional refers only to physicians as defined by section 1861(r) of the Social Security Act.

Physicians across the nation have increased their adoption of Electronic Medical Records (EMR) according to the Electronic Medical Record Systems of Office-based Physicians: 2009 - 2010:
"Additional survey data from National Center for Health Statistics show that significantly increasing numbers of primary care physicians have already adopted a basic EHR, rising by 50 percent from 19.8 percent of primary care physicians in 2008 to 29.6 percent in 2010."
This data was published by the Centers for Disease Control and Prevention on December 8th, 2010.

Dr. John D. Halamka of Harvard Medical School, estimates that only 2% of physicians have a "full-featured" EMR (2010).

"Full-featured" EMRs have all the bells and whistles that define the Meaningful Use criteria (from Dr. Halanka's blog):
  1. Computerized Physician Order Entry (CPOE) - and different orders, such as physical therapy electronically.
  2. Drug-drug interaction checks
  3. Drug-allergy interaction checks
  4. e-Prescribing
  5. Report patient demographics
  6. Report PQRI quality measures electronically
  7. Maintain active problem lists
  8. Maintain active medication lists
  9. Maintain active allergy lists
  10. Check smoking status
  11. Check vital signs
  12. Clinical Decision Support systems (CDS) to improve quality and save time - right now, most physical therapist EMRs provide reminders and prompts for charge capture and revenue enhancement which, while perfectly rational, do little to enhance clinical quality.
  13. Formulary checks
  14. Advanced directives
  15. Incorporate lab results as structured data
  16. Generate patient lists
  17. Send patient reminders
  18. Electronic outpatient notes
  19. Electronic inpatient notes
  20. Electronic Medication Administration Records
  21. Provide an electronic copy of health information
  22. Provide a copy of discharge instructions
  23. Patient specific educational resources
  24. Web-based download of inpatient records
  25. Provide clinical summaries for each office visit
  26. Timely electronic access
  27. Measures for clinical summaries and timely electronic access
  28. Online Secure messaging
  29. Patient preference for communication medium
  30. Patient Engagement
  31. Perform test of HIE
  32. Perform Medication reconciliation
  33. Provide summary of care record
  34. List Care members
  35. Longitudinal care plan
  36. Submit immunization data
  37. Submit reportable lab data
  38. Submit syndromic surveillance data
  39. Ensure privacy
Many of these Meaningful Use mandates do not apply to physical therapy and physical therapists are not considered "eligible professionals" but many of us are still forging ahead with EMR and CDS purchases..

PhysicalTherapyProductsOnline poll of 19,000 rehab professionals

I'm not waiting on the world to define my future - I'm defining my future by investing in the tools of tomorrow.

In 2011, I'll spend several thousand dollars on software coding for a proprietary Clinical Decision Support system that is HITECH compliant using Treatment Based Classification to improve quality and get better outcomes.

How about the rest of us?

Will you spend money on Electronic Medical Records software in 2011?

Tuesday, January 18, 2011

Aimee Mullins Breaks her Physical Therapists' Theraband

Aimee Mullins "hates" her physical therapy sessions until her doctor empowers her to see herself as "able" to break the yellow, red and green Theraband elastic tubing she uses to strengthen her bilateral below-knee amputations.

Aimee describes her childhood physical therapy sessions at TEDMED 2009:

Aimee makes me ask myself if I have always enabled my patients or have I assumed, as Aimee says society assumed about her as she grew up, that people without lower limbs are defined by their bodies.

Have I expected less of my patients because of what I know about their physical, emotional and, often invisible, limitations?

Or, like Aimee's empowering doctor, have I encouraged my patients to break their Therabands?

Wednesday, January 12, 2011

Physical Therapists and Physical Therapist Assistants Invited to Florida West Central District Meeting

The University of South Florida School of Physical Therapy is hosting the West Central District Meeting on Saturday, January 15th from 11am to 5pm. Lunch is provided.

I will present the most recent material from my new book, Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting. The book is in editing and is due out in hardcover on April 30th, 2010.

The format of the meeting will provide 5 hours continuing education from my material and 1 hour for the business meeting. Lunch will be served form 1 to 2pm.
The USF School of Physical Therapy is located here.

Our agenda will cover these five topics:
  1. Medicare "Improvement Standard"
  2. Accountable Care Organizations (ACO)
  3. Clinical Decision Support systems (CDSs)
  4. Treatment Based Classification (TBC)
  5. Physical Therapist Decision Making
I anticipate that about 50% of the time (~2 hours) will be spent discussing and demonstrating the various decision rules (TBC and Medical Screening). What You Will Learn and the Objectives for this portion of the program are as follows:

What You Will Learn
  1. What is the Bayesian approach to problem solving? How can we determine the prevalence of the condition in our patients? Which tests do we use to make the diagnosis?
  2. How to use likelihood ratios to determine the value of clinical testing. What if the likelihood ratios are not published?
  3. What is Treatment Based Classification (TBC) for physical therapy? What are some other types of classification in rehabilitation? Why do we need to classify our patients?
  4. What are Clinical Prediction Rules (CPR) and how are they used to screen for pathology? Why should physical therapists screen for pathology?
  5. How can electronic Clinical Decision Support (CDS) tools improve your productivity, improve your processes-of-care and improve your patient outcomes? How is Clinical Decision Support (CDS) different than an Electronic Medical Record (EMR)?
  6. Will the use of TBC treatment algorithms lower healthcare costs?
  7. Who is qualified to use TBC and CDS algorithms in the clinic? Can Physical Therapist Assistants apply these tests?
  8. What proportion of your work should be algorithmic? What proportion of your work should be naturalistic?
  1. The learner will become familiar with probabilistic decision-making styles in physical therapy.
  2. The learner will learn how to evaluate clinical tests and measures based on their diagnostic accuracy – can they rule-in or rule-out certain diagnoses.
  3. The learner will become familiar with the hierarchy of evidence development and will learn when the clinical judgment of the physical therapist is necessary to apply decision rules.
  4. The learner will be able to distinguish between the features of an electronic Clinical Decision Support system and an Electronic Medical Record.
  5. The learner will become familiar with literature describing the impact of CDS systems on the process-of-care and patient outcomes.
  6. The learner will become familiar with literature describing the development of TBC in physical therapy and CPR in medicine.
Since I am a practicing clinician I will try to provide "real world" clinical examples of how we use TBC within the bounds of the daily physical therapy productivity demands, Medicare compliance mandates and the new challenge of developing an electronic medical record.

I hope you can make it!

Thursday, January 6, 2011

Physical therapists Can Fight the Medicare Improvement Standard with Patient Stories

Bob and Joanne are near the end...
Joanne can no longer care for Bob, who is increasingly weak and debilitated and is facing institutionalization despite a strong will to work hard, stay in his home and a loving spouse who supports him.

It didn't have to be this way...

Bob was discharged Jan 5th, 2010 from outpatient physical therapy working on falls risk prevention.

The Congress in 2010 failed to implement the Exceptions Process to the arbitrary $1,870 "PT cap" on Physical Therapy services in a timely manner and the patient elected to discontinue services (self-rationing) rather than risk hitting the cap with no Exceptions Process.

In January, Bob was not demonstrating measurable progress in a timely manner but had obvious deficits in mobility, self-care, safety and daily activities which limited his independence and caused a burden on his spouse, Joanne.

The Exceptions Process was finally implemented March 23rd with the signing of the PPACA but Bob and Joanne were lost to follow-up at that point and didn't get word.

Bob returned to outpatient physical therapy Nov 10th, 2010. At this time, we are able to document a measurable DECLINE in function, less strength, slower walking, greater use of assistive devices, higher (quantitative) falls risk and greater dependence on his spouse.

Click on ABC Functional Progress Graph to enlarge
We believe, and the patient believes, that the informal, non-statutory, widespread insistence on the Medicare Improvement Standard has led to a denial of physical therapy care and a greater risk of disablement, future institutionalization, chronic pain and future falls risk.

Bob has indicated a willingness to tell his story, in his own words - further, Joanne will describe the additional burden caused by the Medicare Improvement Standard and its financial corollary, the arbitrary cap on physical therapy services.

We can provide evidence of the patient's decline in in function from January to November 2010 - the period he self-rationed his care because of the Standard. We use multiple, validated measures of function recommended by Medicare and supported by the medical literature.

Bob and Joanne would very much like to spend their time together in their home, in comfort and dignity, rather than an antiseptic institution filled with strangers.

What can we do?
click image to enlarge
The Center for Medicare Advocacy would like physical therapists to provide stories of real patient burden faced by people who are unable to get their needed physical therapy as a result of the Medicare Improvement Standard.

The Medicare improvement Standard is illegal but physical therapists have long been taught by self-appointed Medicare auditors that "maintenance therapy" is not allowed and that patients must "improve" if we are to treat them and get paid. According to the Center for Medicare Advocacy...
"...the Improvement Standard conflicts with the law, it has become deeply ingrained in the system and ardently followed by those who provide care and those who make coverage determinations..."
This situation will continue unless physical therapists larn to speak truth to power and get patients to tell us their stories. Often, we are the ones telling the patient that we cannot see them - because we are afraid of Medicare.
"Beneficiaries are told Medicare coverage is not available if their underlying condition will not improve, if they have "plateaued," are not likely to improve, or if they need "maintenance care only".
As a result it keeps people with debilitating, chronic conditions from receiving the care they need. "
Many times, I have been in the position of telling patients I cannot see them when they've "plateaued" and their chronic condition is not improving - yet, I suspect that they will decline when they get back home and cannot train intensive, functional activities the way we do in the clinic. According to one Federal magistrate...
"An elderly claimant need not risk a deterioration of her fragile health to validate the continuing requirement for skilled care"
If you have a story, please contact the non-profit, non-partisan Center for Medicare Advocacy and share your patients' story.

Also, comment on this blog to increase its appeal for other physical therapists doing natural search - you can help this effort even if you don't have a patient story.

Thank you for all you do.

Sunday, January 2, 2011

200 Years of Health and Wealth

How do health and wealth interact? This video provides an entertaining look at worldwide healthcare systems over the last 200 years. Most of the past health gains have been made conquering infectious diseases and acute problems, such as heart attacks. Where will the gains in the future come from? Beating chronic conditions. Physical therapists are in position to provide better healthcare for chronic conditions into the 21st century:

(4 minute video)

Leave a comment - what do you think about this video?

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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American Physical Therapy Association

American Physical Therapy Association
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.