The Physical Therapist at the Intersection

I once had the misfortune to witness a traffic accident in an intersection while waiting at a stoplight.

The impact, noise and shock of the accident were over before I quite realized what had happened and, as the two people got out of their cars, I realized that both had legitimate sounding reasons for their actions and that neither had planned to get into an accident that day.

I am reminded of this unfortunate serendipity by these two notices I got today:

The first was an e-weekly from Becker's Orthopedic Spine Review titled 5 Ways for Orthopedic Surgeons to Increase Revenue of which #2 is "Add imaging services to your existing practice".

Becker's states...

"More and more orthopedic practices are offering on-site imaging services, including MRIs."

The second notice is a new study from Health Services Research called The Relationship between Low Back Magnetic Resonance Imaging, Surgery, and Spending: Impact of Physician Self-Referral Status.

"The study compared scan rates for Medicare patients from 1998 to 2005 for 1,033 primary care physicians and 1,271 orthopedists, before and after the physicians acquired MRI equipment..."

I'll bet you can see what is coming next...

"...acquisition of MRI equipment is a strongly correlated with patients receiving MRI scans.
Among patients of orthopedists, receipt of an MRI scan increases the probability of having surgery by 34 percentage points."

We're sitting at the intersection, watching traffic, wondering when we'll hear the impact, noise and shock of the accident.

What If Physical Therapy Worked Like Air Travel?

The patients' frustration is palpable...



Thank you to Healthcare Technology News for this video (7:01min).

A Physical Therapist at the American Telemedicine Association's Annual conference

The American Telemedicine Association (ATA) is coming to the Tampa Convention Center here in Florida on May 1st to 3rd, 2011.

The ATA 16th Annual International Meeting and Exposition is the world's largest focusing exclusively on telemedicine and health.

I will attend the meeting representing PhysicalTherapyDiagnosis.com and I will interview several important people in the telemedicine industry. Among the luminaries I've already scheduled:

• Jean Bisio, President of Humana Cares, will present Emerging Markets in Federal Telehealth from 4:15 - 5:15 p.m. on Tuesday, May 3rd and I plan to attend this event - booth #1117.
  
  
• Jay Culver will demonstrate the Total Exam Camera by GlobalMedia - booth #717.
  
  
• IDEAL LIFE, the industry leader in remote health management solutions - booth # 1617.
  
  
• MD2GO, Sony's remote HD IP camera system, is designed to enable HD Video communication between a healthcare professional and a patient - booth #416
  
  
• Louis Burns, CEO of Care Innovations, is participating in the Emerging Markets for Remote Monitoring Applications roundtable on Monday, May 2, from 1-2pm in the Plenary Ballroom C.
  
  
• Alice Borrelli, Director of Global Health and Workforce Policy for Intel, is participating in the Transitioning Successful Pilot Studies into Mainstream Applications roundtable on Monday, May 2, from 3-4pm in the Plenary Ballroom C.
  
  
• Intel-GE Care Innovations™ has its blog set up so you can see some of the innovative, new telemedicine devices available this year.

I encourage physical therapists, especially private practice therapists and those in a position to lead their healthcare organizations, to learn about and perhaps embrace these technological changes - not for the sake of either change or for technology - but because of the promise that they bring to make better our patients lives.

FPTA Legislative Advocacy Meeting

I rode the plane up to Tallahassee with John Walz, PT to the FPTA Legislative Advocacy Meeting on March 14-15, 2011. I had been up the year before but John was new to this process. He worked in outpatient rehab but was totally uninvolved in politics. While I’ve become a bit of a political junkie John was the least political person I know – he liked everybody and everybody liked him.

What made John a candidate for State Advocacy training was his community activism – he was a Boy Scout leader, he held leadership positions in his church and he owned three outpatient clinics in Manatee County, Florida. John had political connections where they counted the most – at home.

One of our conversations on the plane brought to light that he bought insurance policies from our new Republican Representative in the State House. This contact may be valuable in the future as physical therapists seek to present our position to legislators in Tallahassee.

Some of the issues John and I learned this year in Tallahassee were among the following:

• How to approach your legislator by Jack Latvala (R) St. Petersburg – real down-to-earth talk about what legislators need to hear from constituents.
• The CEO of the FPTA discussed FS 486 and the Florida Administrative Code 64B17.
• Tim Richardson, PT discussed fundraising and how to set-up, organize and ensure attendance for your fundraiser.
• Eric Chaconas, DPT discussed the Florida Key Contacts Network.
• Nancy Stewart, JD, our attorney and lobbyist in Tallahassee discussed some current issues:
• PIP fraud and attorney’s fees
• No PIP legislation this year
• Clinic licensure
• Pill mills
• Gene Adams, our attorney and lobbyist in Tallahassee discussed other current issues:
• Consensus prediction for the 2012 session
• No change with PIP legislation
• No need for additional clinic licensure

The following day, the assembled Advocacy members went to see our representatives in their state offices. John met his Representative and we arranged to get together back home in Bradenton to do a barbeque after the 2011 session finishes on May 6th.

On the plane ride home, John and I received a quick, 15-minute tutorial on the legislative process from the outgoing President of the Florida Association of Anesthesiologists.

Anesthesiologists have lobbied seven years under this man’s watch to restrict “Pill Mills” in Florida. 2011 is the first year they are expecting significant legislation to protect their profession. Change happens slowly in Tallahassee.

What you can do to help physical therapy is to identify people in your community like John – your friends, your coworkers or yourself. Don’t worry about political interest or experience. Is this person involved and interested in their community? That’s who physical therapists need to represent our interests in Tallahassee. They’re the ones we need as Key Contacts around the state when important legislative issues come up.

If you or someone you know fits the description like John fits can you recommend them for the sponsored 2012 State Advocacy Training next year in Tallahassee?

If you do, contact Eric Chaconas, DPT at echaconas@usa.edu and let him know you are interested in becoming a Key Contact.  If you're interested in attending State Advocacy mark your schedule for February 2012 and apply for a scholarship.

Creeping Corporate Physical Therapy in California

Business interests in California are prevailing over consumer protection.

New legislation has now passed in two committees to add physical therapists to the list of professionals allowed to be employed by non-professionals.

As of April 5th, AB 783 (Hayashi Bill) has now passed, unanimously in both cases in the Assembly of Business and Professions and the Assembly of Business, Professions and Consumer protection.

The new legislation will circumvent the intention of California's Moscone-Knox Professional Corporations Law that passed in 2003, which is to protect the actions of professional from being corrupted by corporate business interests, primarily motivated by profit.

The main corporate business interest employing physical therapists is physicians, podiatrists and chiropractors.

Until now, California has been viewed as having one of the stronger professional corporations laws in the country.

The Hayashi Bill reads, in part:

"Existing law regulating professional corporations provides that certain healing arts practitioners may be shareholders, officers, directors, or professional employees of a medical corporation, podiatric medical corporation, or a chiropractic corporation, subject to certain limitations.

This bill would add licensed physical therapists and licensed occupational therapists to the list of healing arts practitioners who may be shareholders, officers, directors, or professional employees of those corporations."

There is heated debate on both sides of this issue: physicians affirm their right to practice medicine, including physical therapy, within their professional license.

Physical therapists oppose AB 783 mainly as an issue of costs - physicans who own their own physical therapy clinics drive up service volume by 30% and reimbursement by 40%.

POPTs by the Numbers

This recent article says it all...

From Stephen Noonoo at Physical Therapy Products.

What I Learned at Graham Sessions 2.0 - St. Augustine

"We're plankton in the healthcare sea..."

"We pursue celibacy policies..."

"I don't like the term splinter group!"

"Physical therapists are risk averse..."

"What happens at Graham Sessions, stays at Graham Sessions!"

The last statement, I am sure will be OK to say, came from our moderator Steve Anderson, PT. Steve was one of the originators of the event, designed to be a...

"...safe environment for discussing new ideas, asking questions to better understand problems, or advance ideas on possible solutions with no real barriers of strict structure..."

This regional Graham Session was held at the University of St. Augustine on April 9th, 2011. About 45 physical therapists attended.

I stood up and spoke several times on issues I felt knowledgeable about and was most often answered with wise responses that broadened my understanding of physical therapists' issues.

I don't know if I contributed much but I learned a lot.

I just wish I could blog the names of the people who said all the great stuff I heard.

To find out who said what, plan to attend the national Graham Sessions in Charleston, South Carolina in January 2012.

Physical Therapists Can Get Involved With Medicare

First Coast Service Options (FCSO) requests provider participation in its quarterly virtual meeting, the Provider Outreach and Education Advisory Group (POE-AG).

FCSO is the Florida Medicare intermediary. Membership is free and your participation is important.

You can sign up here.

Topics covered at the April 13th meeting included the following:

• Electronic remittances
• MediFest in August 16-18, 2011 (live meeting)
• Duplicate claims
• Effort to reduce paper remittances
• HIPAA 5010
• Comprehensive Error Rate Testing (CERT)
• Medicare Learning Network

Physical therapists can get involved and contribute to our mutual understanding of these complex issues by joining the POE-AG.

Can Florida Follow Kentucky's Co-Pay Legislative Success?

The Kentucky Physical Therapy Association (KPTA) recently advocated for and successfully passed a new law, SB 112, to prevent insurance companies from charging higher co-payments to physical therapy and occupational therapy patients than they pay for primary care doctor visits.

But, the bill was a surprise from the start...

Dave Pariser, PT, PhD, Legislative Chair of the KPTA, says...

"We had no illusions about getting this passed - we didn't think it would happen!
Our lobbyist called us when I was in New Orleans at the Combined Sections Meeting and told us this bill 'had legs' and that we needed to mobilize our Key Contacts to call our legislators".

E-mail blasts in Kentucky were used to generate and maintain a genuine grassroots effort among physical therapists and occupational therapists. Both the PT and the OT lobbyists were used to persuade legislators to support SB 112.

“This truly was a team effort,” said Mr. Pariser.
“Physical therapists, patients, and occupational therapists came together to advocate for this important legislation.
It just goes to show what we can accomplish when we put our patients first.”

The bill passed quickly in the Kentucky Senate and then unanimously, 98 - 0, in the Kentucky House.

"Be prepared to testify in front of your state legislative bodies" says Larry Benz, DPT and CEO of Evidence in Motion

"This bill is not a mandate, its a patient access bill".

How to Get Started in Your State
Many therapists are calling the KPTA to find out how they can obtain similar legislative relief in their states.

Before the bill was even written, the Kentucky leadership began by listening to their members to determine the needs of their organization.

The membership indicated "Reimbursement issues" were high on their priority list and patient co-pays were the single issue most amneable to change.

To obtain quantitative data on the extent of discrimination against outpatient PT and OT therapists, clinics should record the dollar difference between family physician co-pays and physical therapist co-pays.

Mr. Benz, recommends 20 patients each in six private practice physical therapy clinics. Put this data on a spreadsheet, he says. Do not count automobile (PIP) patients, do not count Medicare patients. Only count private insurance.

Try to find out if there is a big differential between outpatient physical therapist or occupational therapist co-pays - try to determine the extent that the large insurance companies are picking on the little guys.

Once the need for this legislation is determined, the next step is to find a legislative sponsor.

The legislative sponsor for Kentucky was State Senator Tom Buford (R).

Once the sponsor was found, the next step is to mobilize physical and occupational therapists statewide. This is done through your Key Contacts list and meetings in your district with legislators and their staff.

The Kentucky Physical Therapy Association is preparing a kit that will describe actions and strategies states can follow to repeat the Kentucky success.

President, Ramona Carper, PT, DPT:

“The Kentucky Physical Therapy Association pushed hard for this legislation because for too long we saw the detrimental effects that excessively high copays were having on patient care.
The financial implication of excessive copay amounts results in disincentives for patients to participate in physical therapy, contributing to a lack of compliance for their care.
This can result in significant recurrence and downstream costs including further surgery, imaging, and pharmacy.
We hope that SB 112 will provide the patients we serve with some financial relief for their copays and allow them to focus on their most important priority -- getting better, faster.”

Kentucky's new law, signed by Governor Steve Beshear on March 16th will go into effect June 8th, 2011.

Florida's legislative session will end May 6th, 2011 and we are hopeful that we can attach a new bill to current legislation already pending.

Is Your Electronic Medical Record Ready for Medicare ACO's?

Never ask this question at a party with private practice physical therapist clinic owners:

"So, what's the ROI on your EMR?"

Chances are the party-like mood will end and you'll be left alone, staring at your drink, wondering what happened.

Electronic Medical Records never did promise much return even under traditional Fee-For-Service. Now, under new Medicare ACO's these old models promise to return even less.

A new report called Better to Best: Value Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations calls into question the current versions of your Electronic Medical Records (EMR).

The report from the Commonwealth Fund, the Dartmouth Institute for Health Policy and Clinical Practice, and the Patient-Centered Primary Care Collaborative is a consensus statement from a meeting that took place September 8th, 2010.

Today's health IT...

"...was developed to support a traditional fee-for-service, visit-based reimbursement model, with the focus on documentation requirements to support a billing function,"

according to David Nace, MD, a McKesson executive quoted in the report."

"Health IT requires new functional capabilities, such as the following:

• multiple team member access and permissions 
• care management workflow support 
• integrated personal health records
• registry functionalities
• clinical decision support
• measurement of quality and efficiency
• robust reporting.

 An interconnected health IT network with key capabilities that optimize engagement, coordinate care and support the implementation of value-based payments is required to support Patient Centered Medical Home (practice) and Accountable Care Organization (enterprise) practice transformation."

For a look at a free, functioning version of a Clinical Decision Support system I've been using in my clinic since 2006 to improve quality, such as PQRS, and guarantee Medicare compliance go to BulletproofPT.com.

"Immense Benefits" of Maintenance Physical Therapy

Maintenance therapy is going the way of the dinosaur, the dodo bird and the compact disc...

New, judicial interpretations of the skilled physical therapy and skilled nursing Medicare benefit have found that "improvement" is not necessary for coverage by Medicare and that maintenance therapy may be appropriate for some patients.



I have been a physical therapist since 1992 and, for my entire career, I have had it drilled into my head that we are not allowed to do maintenance therapy on Medicare patients.

It turns out now that isn't true.

Judith Stein, Executive Director/Attorney of the Center for Medicare Advocacy (seen in the above video) says the "illegal" Medicare Improvement Standard is being challenged in a lawsuit filed January 18th, 2011.

The lawsuit, Jimmo vs. Sebelius, may provide relief to patients needing physical therapy services and to physical therapists who want to treat these people.

Listen to this audio webcast announcing the lawsuit against Secretary of Health and Human Services (HHS), Kathleen Sebelius and Medicare (CMS).

According to Stein...

"This is a real problem that is affecting real people every day... some of our plaintiffs have passed away... (waiting for changes to the Improvement Standard)...and are no longer with us."

What about Outpatient Therapy?

Unfortunately, many patients in outpatient physical therapy do not get denials from Medicare when they hit the $1,870 Medicare PT "cap". Therefore, we may not be included in the class action.

Physical therapists have been "educated" to stop physical therapy and discharge patients when we see a plateau and no further improvement.

We have been told these "facts" by our managers and administrators and by Medicare "experts" for at least 25 years, according to the Center for Medicare Advocacy.

Yet, the patients who plateau may be at the greatest risk of a functional decline when we discharge them from therapy.

As a physical therapist manager, I admit, I have told my staff some of these very same things.

We all have plenty of these stories. If you or one of your patients have an advocacy story you may be able to contribute to the lawsuit against Medicare.

Livin' with Indecision

"I understand about indecision
But I don't care if I get behind
People livin in competition
All I want is to have my peace of mind."

Evaluation of a Treatment-Based Classification Algorithm for Low Back Pain: A Cross-Sectional Study published in the April 2011 Physical Therapy Journal helps quantify where algorithmic decision making tools leave off in physical therapists' practice.

Algorithms are new in physical therapy - Australian physical therapists have an average of only 1.2 years of experience with algorithms while American physical therapists have 7.6 years of experience with algorithms.

What did we use before we had algorithms? Intuition.

This study clarifies where algorithms leave blanks that physical therapists need to fill in with intuition.

The treatment based classification algorithms explained the majority of the patients studied. Forty nine percent (49%) belonged to one sub-group and twenty five (25%) belonged to more than one treatment group. Twenty five percent (25%) of the 250 study subjects did not belong to any treatment group (eg: manipulation, traction, etc).

Is is possible that every physical therapy patient will belong to one and only one treatment group? Have we described all of the groups? If not, how much our our practice is left to intuition?

Algorithms are important because they allow physical therapists to create sub-categories of patient that respond well to our interventions. These sub-categories can be analyzed for long-term outcomes.

High quality outcome studies based on well-defined sub-categories will surely show larger treatment effects than current studies. Better outcomes will prove physical therapists' worth in the reformed, more competitive healthcare system.

Medicare Accountable Care Organizations May Help Physical Therapists

New guidelines for Medicare Accountable Care Organizations (ACO) may help physical therapists become more important players in America's healthcare system.

However, physical therapists are currently not categorized as ACO professionals by the Secretary of Health and Human Services (HHS).

The new guidlelines will, hopefully, add clarity to vague promises and hopeful expectations currently voiced by Medicare officials:

"An ACO will be rewarded for providing better care and investing in the health and lives of patients," said CMS Administrator Donald M. Berwick.

"ACOs are not just a new way to pay for care but a new model for the organization and delivery of care."

Leaders in the commercial healthcare marketplace are more forthcoming. Karen Ignani, CEO of America's Health Insurance Plans, said ACOs presented...

"an opportunity for Medicare and Medicaid to build on the successes of the innovative payment systems that exist in the private marketplace today to improve the quality and safety of patient care and help put the health care system on a sustainable path."

I can't help but think that Ms. Ignani was speaking of innovative delevery models, like the Virginia Mason experiment from 2006, where patients with lower back pain went first to physical therapy, skipping the expensive MRI and neurosurgical referral.

Virginia Mason makes sense except in the current econoomic model: fee-for service.

Fee for service rewards greater productivity but not innovation.

The more cost-effective Virginia Mason became, the bigger financial hit the medical center took.

"Everyone gained but Virginia Mason," says its chief of medicine, Robert Mecklenburg.

The promise of the ACO model is more experimentation like Virginia Mason but the risk is that providers will try to consolidate to gain market share and drive up prices.

Again, Karen Ignani:

"...ACOs could accelerate the trend of provider consolidation that drives up medical prices and result in additional cost-shifting to families and employers with private coverage.