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.

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.

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?

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:

• Use graphic displays of patient functional progress 
• Use the FCSO Interactive Worksheet to understand what documentation is required for Medically Necessary services.
• Consider additional justification statements when the physical therapy services exceed the initial treatment period, typically one month.

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.

State	Overpayment
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.

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.

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:

11. 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.

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.

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.

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 Activity	Rank	Cost to American Patients (in millions of dollars)
Expensive Brand Name Statins for Hypercholesterolemia	1	$5,800
Dual X-ray (DEXA) bone scans for Osteoporosis	2	$527
ANY imaging for Lower Back Pain	3	$175
Antibiotics for Children with Viral Colds	4	$116
Pap Tests for Patients Under 21 years of age	5	$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.

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.