"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

Thursday, March 31, 2011

This guest post is by student Alexis Bonari.

Yoga Poses For Vertigo

Although yoga has been touted in the west to be a fashionable cure-all hobby, it is none of those things — it is, in fact, more. Yoga can aid a willing and patient practitioner to unite one's body, mind, and breath, something no ordinary prescription pill can manage.

Vertigo has many causes and no single cure. One practice that can do little harm, fortunately, is yoga, which can improve your balance and strengthen your nervous system to keep dizzy spells at bay. Moreover, as you learn about yoga, you learn to take better care of your body by eating healthfully and reducing sodium intake—both critical to staving off vertigo. Dedication to yoga will thereby improve your focus and connection to your body so that you know sooner when something isn't quite right. With time, you will acquire a deeper and more personal knowledge and appreciation for your body that will allow you to change your lifestyle to a healthier one with fewer episodes of vertigo.

Yoga and Overall Health

Unfortunately, simply practicing a few asanas (poses) won't do much for your health or preventing vertigo. In addition to seeing a physical therapist, look around for a local yoga instructor and inform him or her about your condition. Your instructor will select specific poses and sequences to help with your balance and organ health. Meditation and breathing exercises will also aid in your battle of mind over matter.

Basic Balancing Poses

The following are basic yoga poses that have been used to provide relief from vertigo. Once you have embraced a healthful lifestyle, these poses may come in handy before and during bouts of vertigo. Although poses like Halasana (plough pose) and Sirsasana (head stand) may prove difficult and even harmful to beginnings lacking instruction, the rest are easy and difficult to perform hazardously. Discover Pranayama (breathing techniques) to begin your yogic healing, and move on to various poses from there.

Bio: Alexis Bonari is currently a resident blogger at College Scholarships, where recently she's been researching typical student loan debt as well as direct loans for students.

Whenever this WAHM gets some free time she enjoys doing yoga, cooking with the freshest organic in-season fare, and practicing the art of coupon clipping.

Wednesday, March 30, 2011

Doctors, Free Markets and Healthcare Exchanges

This is a guest post from Lou Galterio, MBA, HIMSS Fellow, CPHIMS
President and CEO
The SunCoast RHIO, Inc.
Sarasota, Florida

Response to the Department of Health and Human Resources
Center for Medicare and Medicaid Services

ACO RFI, 42 CFR Chapter IV

The SunCoast RHIO, Inc. of South West Florida

This document is in response to the request for comments on aspects of the ACO model. We would like to submit our thoughts and ideas for consideration. I represent the SunCoast Regional Health Information Organization (RHIO), Inc and Health Information Exchange (HIE). Our website is www.SunCoastRHIO.org . Our organization appreciates this opportunity to be part of this effort and have our voice heard during this very important point in time as our country takes this very necessary step in the evolution of health care delivery.

The SunCoast RHIO is an organization that both serves and has as its members, doctors, hospitals, and consumers. Doctors have a voice in the RHIO and we listen very closely to what they say. We offer our services to the counties comprising the South West Florida region and we also work closely with the Regional Extension Center here. We are aligned with the efforts of our State Government and the various county Health Departments. Our organization is structured to make the most out of public – private collaborations and collaborations utilizing a non-profit and for profit sustainable business model.

We will address the CMS request for information regarding policies and standards, capital access, attribution, assessment, patient-centeredness, and quality performance standards. We will not address the final point of additional payment models as we are not qualified and this knowledge is beyond our expertise.

Before that, I would like to make four very short observational comments on this topic. The first regards the general resentment and perception of blame as to how we got to the point of high cost healthcare we are at now. Some say it is the high price of doctors, others say the insurers and payers, and most just don’t know. All agree however that the present state is no longer financially tenable.

There is no one to blame. One can look at the history of a healthcare entitlement public perception evolved from practices during World War II, or the high cost of medical education, or the poor cost accounting methods used in the Charge Master recovery models of early hospitals as they evolved from organizations focused only on the poor. The fact is that any system, left unchecked, tends to grow until it reaches a point of instability. This extends over nature and to business. Our friends at the FTC know this well. It is the nature of things as they evolve and it is in the public interest to insure that there are checks and balances in place to avoid this yet do not inhibit free market innovation and self determination. Because of the complexity of this field, we are just getting to that point now. We are all in this together and together is how it will be fixed.

The second statement is an extension of this first point. We live in a country based on free market enterprise system. Here, people can achieve their dreams of wealth and success, as they define it, without fear of being controlled and in partnership, not competition, with the government that serves them and represents them. It is this freedom to innovate that has made us and will continue to make our system the best in the world.

Our next statement is a natural outgrowth of the preceding thoughts. Doctors are intelligent self motivated individuals. They are the cream of the crop of our society. There are many industries where individuals like this could have entered to simply make a good deal of money. But, many have gone beyond that by choosing to dedicate their lives by caring for others and relieving pain and suffering.

From the doctors we speak to every day, most want to practice their profession, not feel commoditized, and be able to make a comfortable living based on reward commiserate - either in dollars determined by the supply and demand for their skills or the satisfaction of helping others. In the vast majority of cases, it is both. Doctors in our RHIO are individuals. They make decisions of life and death. They are often times entrepreneurs and demand a say in how their life evolves and not to have it dictated. They depend on themselves and their colleagues in determining their own destiny.

Finally, we wish to emphasize the benefits of technology and a technology platform as an enabler for an ACO. The landscape is quickly turning from that of brick and mortar offices to one of electronic practices where innovation and business opportunity is encouraged and economies of scale are made available at the speed of electrons. Doctors can be free to practice in this environment without being encumbered by an expectation of becoming technologists themselves unless they choose to. Doctors can choose ACO’s to belong to, build their practices within them, associate as they see fit at the time they wish, and be free to quit and move on to others when the ones they are in fail to serve the purpose. This applies to the consumer as well as the payer and is one of the reasons we feel that a RHIO can be both a service organization supporting an ACO, multiple ACO’s, or an ACO itself, serving far flung doctors and specialists determined not only by geography but by specialty and demographic desired.

Policy and Standards:

We feel an important part of the success criteria of an ACO will be to support a doctor’s will to have choice and control over his or her own destiny. An ACO needs to encourage free enterprise. Doctors do not want things forced upon them. This includes dictating ways to practice or technology tools that they must use without say. We also acknowledge the need to have a basic system in place that serves this drive yet insures a consistent measure of quality, as defined by evidence and patient experience, demanded and deserved by the public and their elected representative government. We believe doctors want this also, not only as providers of care but as patients themselves.

Policies and Standards for ACO’s need to address this. There is numerous guidance within Medicare to guide practice operations and clinic building. There are quality indicators that are being standardized. This should not become an endpoint. Quality demands will change over time as sure as patient preferences and public policy does. However, there are core measures that are permanent.

An organization like a RHIO can package the necessary business and legal requirements to create an ACO model. Policy and standards become the job of the organization challenged to deliver the infrastructure. This gets us away from a payer, hospital, or government lead. Joining a RHIO is a choice that doctors freely make and can leave anytime. A potential set of policies and standards can be attributed to a lead organization sanctioned by CMS for Medicare and Medicaid.

The second aspect of course is compensation. If we have a core set of quality indicators that, when achieved, leads to a core reimbursement, it sounds allot like a base salary – and one that everyone gets regardless of contribution or differentiating practice or ability. It is true that savings can be shared for efficiencies above the standard set but this will not be significant. Secondly, what happens when the savings run out or the chance to create efficiencies is no longer obvious? Do we move to a base compensation that discourages individual effort and achievement?

We need a way to offer reward and self reward. By giving physicians the ability to innovate by choice of affiliation and potential return by being free to build or associate with whomever they wish, we can encourage the benefits only a free enterprise system can afford. By having an overall set of guidance and tools certified by CMS and executed by the organization of choice to the provider, instead of dictating practice, we can look forward to huge rewards, not only determined by how much we can cut and make mechanical but also by unfettered opportunity.

Access to Capital

By encouraging an ACO that is a business organization that follows set basic requirements yet offers the provider choice and innovation, we help foster an organization that can be for profit, not for profit, public, private or any combination.

This approach allows the innovation displayed by members to attract patients, if they are good, charge a partial concierge fee, or work with banks to encourage HSA participation directed at the consumer investment to their doctor of choice, doctor group, and evidenced by their own health care as reported by their peers. Return to the consumer is both personal and financial. Traditional investors could evaluate where to invest based on ROI determined by patient choice which leads to provider returns, practice size, and referral patterns created by good medical practice in line with satisfied and self motivated doctors and basic public policy.


Attribution would be addressed by patient choice and provider choice. Technology encourages, supports, and enables fast movement and the access to the best doctors appropriate to the need. Price works itself out in a free market checked by the awareness that a totally free market tends toward monopoly and a totally controlled market leads to inefficiency.

Beneficiary Experience, Patient-Centeredness and Quality

Patient experience lends itself to patient access tools that are trusted, perceived centralized, and easy to use. By having a co member organization like a RHIO supporting the ACO or being one itself, we can encourage patient experience sharing through Personal Health Records and easy access that is a trusted source. RHIO’s strive to maintain this ease of use and accessibility. This is further supported as we offer portals to HHS Government Databases and as supportive to our State’s efforts in Health Information Exchange. The concept of a Medical home is one that is both an individual and a group experience. People not only care for themselves but for their loved ones. If a way were available to have access to all of these abilities as a family focus, it would be used.

In addition to patient experience, we support provider experience. In one of our new offerings we emphasize provider satisfaction and also recognize that providers trust providers. We support a doctor only blog called Sermo that we can’t get into all our selves. We try to provide a one stop shop access point to providers and patients.

We hope to be a portal for the new insurance clearinghouses by further allowing levels of access to patients and providers to these offerings.

We work closely with quality measurement and analytics through the standards, organizations, payer experience, the best of P4P experience from the past, and a current agreement to utilize DARTNet, an AHRQ funded database, for outcome measurement. We hope to encourage usage of and distribution of Comparative Effectiveness Research and NIH discoveries and studies pertinent to the patient in a language they can understand. By doing this, we can show statistical success or failure by comparing experiences not from a minimum of 5,000 patients but from millions as reported in a consistent manner on behalf of all ACO’s and not just those formed to served a defined region or a concentrated population.

This is not a plug for a RHIO though; it may sound like it, but as a comment to this RFI and something we are passionate about. In that, we strongly believe that a similar organization or a new one never thought of before can act as the engine for an ACO grid that supports provider choice, government guidance, innovation, and public and private capital and interest. This can go beyond Medicare and can enable this experience even in a self pay, private, or even a charity approach.

Thank you for the opportunity to respond.

Lou Galterio, MBA, HIMSS Fellow, CPHIMS
President and CEO
The SunCoast RHIO, Inc.
Sarasota, Florida

Sunday, March 27, 2011

Doctor Happy and the Silent Treatment

A new study highlights an old problem in medicine that leads to patient harm.

A new study from VitalSmarts, the American Association of Critical-Care Nurses and the Association of Peri-Operative Registered Nurses (AORN) called The Silent Treatment describes several categories of "undiscussables" in medicine:
  • Dangerous shortcuts
  • Incompetence
  • Disrespect
As I shared here, even physical therapists are subject to events that lead to the silent treatment.

Teams of healthcare workers in the future will need to learn positive ways of influencing each others' behavior but not bullying, yelling or disrespectful behavior.

The silent treatment happens anytime communications between physicians and other workers break down. "Other workers" can include nurses, physicians' assistants, physical therapists or even clerical people. My experience with a particular orthopedic surgeon falls under the "disrespect" catagory.

Acoording to the American Association of Critical-Care Nurses (AACN):
"More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16 percent confronted their disrespectful colleague."
My story goes like this:

The orthopedic surgeon called me two weeks after the patient's operation. I had seen the patient once, or maybe twice, at that point, for rehabilitation of his full-thickness rotator cuff repair. The patient was on the standard six week protective protocol, passive range-of-motion only and pendulum exercises at home.

The incision was still swollen and tender. Motion, even passive motion, was quite painful. The patient was still having trouble sleeping at night. Therapy consisted of maybe 20 minutes of passive mobility in six directions, the aforementioned pendulum exercises followed by electrical stimulation and ice.

I got called in the middle of the work day by the physician who we'll call Dr. Happy. When I picked up the phone, Dr. Happy practically yelled,
"Tim! What the hell are you doing letting my patient get stiff?"

I knew better than to argue. "He's still very sore, Dr. Happy" I said.

Dr. Happy continued, "You'd better improve internal rotation! He can't get his arm up his back! He's going to get a frozen shoulder!"

"We won't let that happen, Dr. Happy!"
I said.
That might have been enough - a sharply worded reminder to improve joint motion - except for what came next.
"You like my referrals - don't you?". It wasn't a question.

"Yes sir!" I said, dreading what I knew was to follow.

"You'd better not let him freeze up or I won't send any more referrals to your clinic!" growled Dr. Happy
The question is not whether Dr. Happy was justified in chewing my butt, or whether my patient actually was stiffening up (he wasn't).

The questionable behavior is Dr. Happy's abusive, disrespectful and bullying attitude that, unfortunately, was not seen as abnormal in the culture of American medicine.

Nowadays, hospital safety is changing as a result of checklists, computerized decision support tools and new surgical protocols. But, these new tools won't create a safe culture as long as people disrespect each other to enforce a culture of silence.

Tools don't create safety, people create safety.

The culture of silence is beginning to change.

Wednesday, March 16, 2011

Key Contacts Important for Physical Therapist Advocates

"They'll take your money!" said the Senator.

He laughed as he stepped into the elevator. We joined in the laughter, aware of the power differential he created and agreeing with the truth of his words.

"Everybody's up here in Tallahassee playing defense. Even if you physical therapists have nothing on the table this session you need to stay involved."

He was tutoring us now. We remained silent and nodded respectfully.

I was standing next to my former employee and the current owner of three outpatient physical therapy clinics in Bradenton, Florida. I own one clinic. Together, our combined ages just matched the Senator's age.

The Senator knew us from visits to his office back in the district. He was always cordial but I had seen him show a healthy distrust of medical professionals - his construction business paid heavy workers' compensation premiums every year and Medicaid fraud-busting was his top priority.

Could we persuade him to see physical therapists differently?

"The papers keep saying you will run for one of Florida's two open Congressional seats in 2012?" I said

"My wife wants me to retire - but I'm having a great time!"

The Senator got off the elevator to go to his committee meeting. "See you boys later!" he said over his shoulder.

Being a Key Contact

Physicians have more money than physical therapists and chiropractors have been a political force in Florida for longer than I have been alive.

So, what can physical therapists bring to compete with dollars and political precedence?

Compelling stories and a genuine focus on the patient.

Physical therapists can tell stories about helping people walk after devastating accidents. Or, we can describe simple, safe interventions that enable people to live independently - all without drugs or surgery.

Witness the effect of stories and a genuine patient focus on this improbable political victory by Larry Benz, DPT and a determined grassroots effort in Kentucky:
"Get organized, be bold, and go for it.

PT's don't go in front of legislators very often and when we do we have great patient testimonies, empirical evidence, and a host of intangibles that at the end of the day are easy to understand and resonate with many.

While you can never underestimate the power of the political process, you can prevail."
Physical therapists are not natural political operators - that's what makes us stand out in a positive way in places like Tallahassee.

The Legislature is divided into two houses. The House of Representatives and the Senate make laws that govern Florida. There are 120 members of the House of Representatives and 40 members of the Senate.

We need your help.

If you have considered helping your professional association and you feel that you could share your patients' successful stories or speak up for the profession please contact Eric Chaconas, DPT to be added to the list of Florida's Key Contacts.

Sunday, March 13, 2011

Disrupting Hospitals

Clayton Christensen predicts hospitals will need to break-up their revenue model as healthcare reform finds ways to improve quality and lower costs.

If you develop a product or service that helps people do something more affordably and conveniently, something they’re not trying to do, it just never works.

Even if they should do it, if they’re not trying to do it, it never works.

A lot of problems with wellness programs: becoming healthy is not a job people try to do until they’re really sick.
Clayton Christensen describes three revenue streams that hospitals try to manage now:
  • Intuitive medicine, like you see on House, MD.
  • Value-added medicine, like an orthopedic surgeon replacing a Grade IV arthritic knee.
  • Networked communities, available by subscription, of people with chronic care needs and unhealthy behaviors that need education, emotional support and behavioral change tools.
..."rather than expecting our complicated, expensive hospitals to become cheap.

What we do is we bring technology to outpatient clinics so we can begin doing there the simplest of the things that today require a hospital.

It's by enabling lower-cost venues of care and lower cost care-givers to do progressively more sophisticated things that's the mechanism by which health care becomes affordable and accessible not by somehow praying that the expensive one's will become cheap

Physical Therapy for Iliotibial Band Syndrome

After getting cracked, pushed, and poked around by two chiropractors, one doctor, and one masseuse over the course of five years, I’d given up on healing my hip snapping syndrome. Everyone said it was something different, and they all recommended I refrain from physical activity for one year (an entire year!) or until the snapping desisted.

It was by chance that, one day while playing tournament-style paintball with a friend, I complained about my hip problems off the field and one of the other players suggested to me that it was Iliotibial Band Syndrome. I could barely get the words out of my mouth without tying my tongue into knots, but the friend—a physical therapist—began listing common symptoms, all of which I had.

  • An audible snap or click in the hip, which may be painful or painless
  • The location is lateral (indicating the iliotibial band or gluteus maximus)
  • Occasional sensations of the hip subluxing or dislocating
  • Duration of symptoms lasting several months or years rather than days or weeks

Going to a Physical Therapist

I followed up our conversation with an appointment at his clinic. I explained to my therapist that back in 2005, whilst stretching to train for my black belt in Tae Kwon Do, I had felt sharp pain in my right hip and, after returning to my feet, felt as if my right leg wasn’t popped into the hip socket.

Snapping hip syndrome is, among athletes, most often caused by repetitive overuse. She conducted Ober’s test on my right leg (wherein I laid on my unaffected side and dropped my affected leg to the examination table; the present of pain along the lateral side of my thigh indicated a tight IT band) and surmised that I had ITB syndrome. The snapping was being caused by the iliotibial band snapping over the greater trochanter (the top bulge of the femur). As an athlete, repetitive overuse of my hip and sudden loading of it (kicking targets in my case) had caused the symptoms. This also brought my gluteous maximus into the picture, as it regulates flexion at the hip and is a powerful extensor of the thigh and trunk when the legs are fixed. Although relaxed when standing, said muscles are used extensively in running, climbing, rising from squatting positions, and the like. Strengthening these muscles as well as my core would seem to be key in healing my ITB syndrome.

Ongoing Physical Therapy

My therapist assigned me a program of light aerobic activity followed by stretching and strength training that would regulate proper hamstring, hip flexor, hip adductor, and iliotibial band movements. Although surgery, orthotics, and cortisone steroidal treatment are available, I prefer non-aggressive and holistic treatment, so I opted on physical therapy alone. Since I had already been practicing yoga for the better part of a decade, I researched poses that would prevent IT band pain. The most helpful poses have been:


Cow face pose

Half lord of the fishes pose

Reclining big toe pose

Half frog pose

Had I not visited a physical therapist, I would still be complaining about a pain I knew nothing and could do little about. Knowing exactly what was going on—and not having to spend any more money guessing what could be going on—was the first relief, but a gradual relief from the pain has been the most rewarding.

Bio: Lisa Shoreland is currently a resident blogger at Go College, where recently she's been researching creative scholarships as well as searching for scholarships. In her spare time, she enjoys creative writing, practicing martial arts, and taking weekend trips.

Break Health Care in Order to Fix It

I'll introduce Professor Clayton Christensen and then I'll get out of the way...

Dr. Christensen wrote a book called The Innovators' Prescription and he wants to solve the healthcare crisis by "disrupting" it.

Dr. Christensen proposes paying doctors based on one of three "tracks" that exist in medicine:
  • Track One is like Gregory House, MD. Dr. House tries to separate the "zebras" from the "horses" - there is a high need for intuitive diagnoses. The process described brings to mind episodes of House, a TV show in which a brilliant but irascible doctor challenges a team of colleagues to find the problem before the patient dies.

    Fee for service would continue to apply to these diagnostic services.

  • Track Two is Fee for Results which would apply for treating conditions that are well understood and have a clearly defined solution -- total knee replacements, colonoscopies, laser eye surgery, implantation of stents, etc.

    These are production problems that will yield to mass production techniques used in other industries. Whether we need expensive orthopedic surgeons at $500,000 per year performing assembly line processes is an open question.

    Obviously, cost savings are available in Track Two.

  • Track Three is user networks for patients with chronic conditions or unhealthy practices to learn how they can help themselves and be motivated to do so.

I believe physical therapy will be a Track Three service that will be completely disrupted from the traditional Fee-for-Service payment model.

Physical therapists addicted to the volume model of providing "more" services will suffer like steel companies and auto companies in Dr. Christensen's video and book.

Watch it.

Let me know what you think.

Saturday, March 12, 2011

Florida Representative is "...for the Docs"

"I'm for the Docs", said Vern Buchanan Florida's 13th District Republican representative in the Congress.

The Congressman was speaking at the Parrish Town Hall meeting on Saturday, March 12th 2011. His response came when I asked if he would support an annual, reoccurring 1% negative update to the Medicare Physicians' Fee Schedule (MPFS).

The Fee Schedule is set to be cut 29% on January 1st, 2012, unless the Congress again intervenes. Physical therapists and physicians are annually whiplashed by uncertainty to the size and the timing of the cuts.

While Vern Buchanan is in favor of aggressively cutting the 12% of discretionary spending that will have minimal effects on future years' spending, he is non-committal on Medicare.

Does the pattern of campaign donations from doctors in the 2009 - 2010 election cycle have anything to do with his voting record?

American Association of Orthopaedic Surgeons$10,000
American College of Cardiology$2,500
American Dental Association$4,000
American Medical Association$2,000
American Dental Association$4,000
College of American Pathologists$3,000
National Community Pharmacists Association$2,000

A law stabilizing the size and timing of the annual Medicare cut at negative 1% would be, in effect, a cost of doing business - just like my annual 1-3% cost-of-living adjustments I pay my employees or my annual 15% increase in health insurance premiums I still provide. These are anticipated costs that I prepare and budget for.

Why not Medicare, too?

Vern Buchanan can act like a leader by cutting spending that will have a real effect on future years. He needs to cut discretionary and non-discretionary spending (Medicare) equally.

Don't just be for the Docs.

Friday, March 11, 2011

Florida Representatives have Concerns about Telemedicine Bill

A new bill covering telemedicine services (HB 505/SB 1882) was read on the full Florida House of Representatives floor on Tuesday March 8th, 2011.

The bill requires health insurers, corporations, and health maintenance organizations issuing certain health policies to provide coverage for telemedicine services.

The new bill prohibits the exclusion of telemedicine cost coverage solely because the services were not provided face to face.

The bill provides coverage under the state plan without a condition that telemedicine services are restricted to health care providers licensed by the Florida Deptartment of Health.

If the telemedicine bill is passed in its present form it would require the insurer to reimburse for services provided by a health care provider not licensed within Florida

This would render the regulation of health care professionals by the respective professional boards, where telemedicine is concerned, moot with regard to out of state practitioners.

Similar telemedicine legislation is being debated in California, Oregon and Washington state right now.

Nurses have created "Nursing Compacts" with government grants that are, in effect, seperate licenses allowing them to practice across state lines.

Physicians have a "special license" that allows them to practice medicine across state lines and still retain the supervision of their state licensing boards.

Why should Physical Therapists be left out of the party?

A recent randomized, controlled trial in the Journal of Bone and Joint Surgery showed that telerehabilitation, in one setting, can produce superior outcomes than conventional Physical Therapy for Total Knee Replacement.

What do the readers of PhysicalTherapyDiagnosis.com think about telerehabilitation services, such as remote video monitoring?

Thursday, March 10, 2011

The "Smart" Electronic Physical Therapists' Office

John gets out of his car to go to his physical therapists' office.

A digital camera records John's 10-foot gait velocity walking up the ramp to the front door.  Another digital camera photographs John's face and, from minute changes in his facial blood flow, calculates his blood pressure as accurately as a sphygmanomometer.

He says "Hi" the smiling young lady at the front desk and presses his thumb print to the electronic sign-in screen.  Since this is John's first visit in over six months he reviews his informed consent form, financial responsibility form and HIPAA form.  He also checks "Yes" on the checkbox that asks if his wants to use the credit card number that is securely stored by the clinic.

An electronic kiosk inquires with an authentic female voice about the John's primary impairment and asks for a self-report using standardized language from validated tests.

After taking about ten minutes interacting with a mix of human and electronic interfaces, John heads back into the clinic.

John spends most of his time with a physical therapist who asks him questions, listens and, most importantly, allows John time to express his needs and problems.  The physical therapist does not have a paper chart, clipboard or computer keyboard between herself and her patient.

A smart goniometer that "remembers" every patient and every limb that it has ever measured is used to measure John's range-of-motion. A smart blood pressure cuff measures his systolic and diastolic pressure. A smart Wii or center-of-pressure device measures John's balance. A smart grip dynamometer measures his grip.

A smart medications list that downloads real-time from the community-wide Electronic Health Record is used to update the clinic Electronic Medical Record for John.

After John leaves his session he goes home and, since he forgot to ask his therapist a question, fires off an e-mail that is automatically routed and recorded in his record.

Later, John receives a text message with the answer he needed from his therapist.  John will receive several timely text messages over the next two weeks, reminding him to do specific therapeutic activities at certain times of the day.

For perpetuity, John will continue to receive a mix of text and e-mail messages aimed at promoting activity and reducing his need for pain medications and unscheduled follow-up visits.

This is not a dream.

Do not pinch yourself.

The only question is this: Who will invent, distribute, pay for and create the future by providing these devices for the physical therapist?

I hope it is the physical therapist.

California Kickbacks

What makes California different?

What is it about the physical therapists in California that puts them in the national spotlight? Is California larger than everybody else? Does California have more physical therapists?

Not according to Dave Powers, Chairman of the California Private Practice Section.

California has therapist leaders that are more committed, more serious and better informed about their rights under the law than many states. They are, incidentally, paying personally to fund the fight against California kickbacks to physicians.

According to Mr. Powers, "We've dug deep into our pockets - this stuff isn't cheap."

The 2003 Moscone-Knox Act is California's version of the professional corporations act that prevents physical therapists from working for physicians, chiropractors, podiatrists or other professions.

Professional corporation acts exist in every state to prevent undue influence over professional behavior by non-professionals. Only physicians can own physician practices and only lawyers can own law practices.

For instance, physicians are not allowed to own physical therapists' practices, according to the Moscone-Knox Professional Corporations Act in California.

Professional Corporation Acts are legal vehicles that prevent improper influence of professional decisions by non-professionals.

Professional corporation acts are relatively new to physical therapists' collective consciousness according to Peter McMenamin, PT. Mr. McMenamin first wrote about this issue in the December 2001 issue of IMPACT, the magazine of the Private Practice Section of the APTA.

Mr. McMenamin studied the issue in his own state of Illinois. He found that Professional Corporations Acts range from Strong to Weak in different states. Physicians and attorneys tend to have Strong versions of the law. Physical therapists and Occupational Therapists practice acts tend to have Weak versions of the law to protect the practice of physical therapy from ownership by non-professionals, like in Mr. McMenamin's home state of Illinois.

Dave Powers met Peter McMenamin a few years ago during a seminar when Mr. McMenamin advised his audience to examine their states' Professional Corporations Act to see if their existing laws were Strong or Weak.

It turns out that California has a Strong law protecting physical therapists.

The September 2010 California Legislative Council decision upholding the California Physical Therapists' Association view of Moscone-Knox affirms that physical therapists are prevented from being hired by non-professionals, including physicians, chiropractors and podiatrists.

In February 2011, Mary Hayashi (D-Hayward) sought to overturn the Moscone-Knox law as it applies to physical therapists with AB 783, a new law that specifically allows physical therapists to work for podiatrists and physicians.

The Quality Issue

PTManager.com has re-posted a patient testimonial from the StopPOPTs.org website of a POPTs patient testimonial.

The patient talks about a physician directing his patient to his own therapy center ostensibly for better communication and oversight. Yet, in her own words, the physician was never in the physician-owned physical therapy clinic.

However compelling this patients' testimony about the poor quality of her physical therapy at the physician's clinic, I believe the patient's message detracts from the central issue facing California physical therapists - cost.

The Cost Issue

It's not about quality, its about cost.

Peter McMenamin says in Exclusive Physical Therapist Ownership of Physical Therapist Services: Economic Foundations for Professional Autonomy :
"...the POPTs issue got sidetracked into issues of ethics and restraint of trade becasue the issue was never analyzed within the historical context of autonomy as practicved by other professions."
Money will resonate the loudest in Sacramento where the state Assembly meets March 23rd, 2011 and Mary Hayashi's AB 783 will be 'fast tracked" to ensure passage.

If the Assembly passes AB 783 it will go to the California Senate where oddsmakers place it at 50-50.

Jeff Worrell of PT Talker.com interviews Paul Gaspar, DPT of Doctors of Physical Therapy in San Diego, California about AB 783.

California has a $25 billion dollar deficit that state lawmakers need to cut. The story that California physicians are receiving kickbacks from owning and referring patients to physical therapy clinics is attracting attention in Sacramento, and from national news organizations.

Overuse of surgery and inappropriate diagnostic imaging litter the headlines of internet blogs and newspaper headlines

You can support the California Private Practice Section (CPPS) in its fight against Hayashi and the physicians' efforts by signing this petition.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
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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.