Task Force Recommends Physical Therapists Use Clinical Intuition to Screen for Fall Prevention

The U.S. Preventive Services Task Force (USPSTF) Recommendation Statement for Prevention of Falls in Community-Dwelling Older Adults was published May 28th, 2012 in the Annals of Internal Medicine and the author's found new evidence promoting...

"...exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Grade B recommendation)"

An extensive evaluation or high-tech balance assessment is not necessary:

"In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (Grade C recommendation)"

Physical therapists should be able to use their clinical intuition to determine which patients are at high risk for falls and for whom physical therapy is medically necessary.

Medicare will pay for physical therapy that is medically necessary to prevent a future adverse event.

In some cases, the physical therapist may be able to apply the -kx modifier attesting that services are medically necessary over and above the 2012 $1,880 combined cap on speech and physical therapy.

Telehealth Potential Remains, Trapped by Regulations and Licensure Barriers

Dr. Alan Lee's Perspective article in the December 2011 Physical Therapy journal offers hope tempered with a dose of pragmatic reality - much work still needs to be done if telemedicine techniques can be brought to bear for the benefit of physical therapists' patients.

Some of the barriers on the provider side identified by Dr. Lee include:

• licensing and credentialing - Alaska and Washington state are the only two states to include telemedicine language in their practice acts. New legislation promoting "license portability" is being prepared for the Congress in 2012.

  “Telemedicine is medicine, just practiced virtually”,

  ...said the office of the bill's sponsor, Senator Tom Udall of Utah. 

On the policymakers' side the barriers include:

• billing and reimbursement - payment for physical therapy services is currently dictated by the setting or delivery method, ie: home health, outpatient, hospital, etc,

Telemedicine's biggest benefit is probably its costs savings to both the provider and the patient.

But, new evidence that telemedicine can impact relevant patient outcomes that are "hot topics" among payers and policymakers is increasing.

Geisinger Health Plan, using telemonitoring technology, has demonstrated a 44% reduction in 30-day readmissions compared to a control group.

How Can Outpatient Physical Therapists Use TeleMedicine?

I imagine a scenario similar to the Geisinger program where patients are followed after discharge to monitor their status and identify risk factors before symptoms occurs, or before an adverse event happens.

Can you imagine Skype connection (available for free on newer laptop computers) with your geriatric patients?

What if you could measure the 10-foot Gait Velocity over Skype and predict the need for Skilled Intervention based on slowing gait speed?

What if Medicare would pay - based on this one measure alone?

Join Pitt DPT Students to #SolvePT

Be a part of the movement!

Add your voice to this Twitter conversation to determine what physical therapy will look like in the future.

Log on today, Tuesday May 22nd, 2012 from 9-10 pm EST the topic will be:

Does Alphabet Soup & New Terms Erode Our Profession?

I recieved this image yesterday in an e-mail from the students at the University of Pittsburgh who have put their full weight behind the movement.

• Rock the boat
• Find solutions
• Be the change

Physician Decision Making "Can't be Trusted" for Organ Transplants

Physicians, in their own words, "gamed the system" for organ transplants and "can't be trusted".

To be fair, physicians were acting in the interests of their individual patients. But, other patients and society in general were the losers.

The ethics and the economics of organ transplants are emotionally fraught and complex. Better to listen to this Planet Money NPR podcast.

FOTO and AthletiCo Proudly Show Physical Therapy Outcomes Tool

From AthletiCo and Focus on Therapeutic Outcomes (FOTO).

This is an excellent demonstration of where all physical therapists are heading - towards an integration of science, technology and caring. (July 11, 2011)

Obesity and Physical Therapy

I don't talk a lot about diet with my physical therapy patients.

I probably should because Body Mass Index - your weight in kilograms divided by your height in meters, squared - is an important predictor of future disablement and death.

However, I don't talk much about diet for one simple reason - I am not qualified to give anyone advice on their food consumption.

Oh, it's not that I don't have the knowledge or experience. Its just that I have no discipline.

I never met a cookie that I didn't like.

Which, I think, is most American's problem - especially those who struggle with obesity.

In The Mathematics of Obesity, MIT-trained physicist Carson C. Chow dishes out his theory of why Americans began gaining weight in the 1970's and have only recently began to cut back.

"Beginning in the 1970s, there was a change in national agricultural policy.  

Instead of the government paying farmers not to engage in full production, as was the practice, they were encouraged to grow as much food as they could.  

At the same time, technological changes and the “green revolution” made our farms much more productive.  

The price of food plummeted, while the number of calories available to the average American grew by about 1,000 a day.  

Well, what do people do when there is extra food around? They eat it! 

...the model shows that increase in food more than explains the increase in weight."

I like Chow's approach to explaining obesity - he doesn't blame individuals. Its not lack of willpower, or a sweet tooth, or "big bones".

Further, Chow's analysis dispells much of the contradictory psuedo-science of WHERE your calories come from - carbs, proteins, fats - its all calories.

However, the answer to obesity will have to come from individuals. And their healthcare providers. The individuals will have to change their eating behavior. Patients will have to control their food intake.

And, physical therpists can help them.

There is an interesting BMI Simulator based on Chow's work at The National Institute of Diabetes and Digestive and Kidney Diseases that is probably too complex for most people.

Bottom line, we'll probably all need help getting our impulses under control. For me, that means fewer cookies (pause, while I brush the crumbs off of my keyboard).

As Chow explained in his New York Times interview,

"It’s so easy for someone to go out and eat 6,000 calories a day.  

There’s no magic bullet on this. You simply have to cut calories and be vigilant for the rest of your life."

The Severity and Intensity Model for Physical Therapists

"I'm sorry, Mrs. Smith, but we can't continue your physical therapy - you've hit your Medicare Cap."

"But I'm doing better and I've not missed even one of my 16 visits. My doctor wants me to finish another month of PT - why won't Medicare pay?"

"Well, that's just it - Medicare will pay but your physical therapist's documentation shows you ARE better and we're afraid if we let you come for more PT then Medicare will deny payment."

"Can't you write down how much physical therapy helps me and how I NEED this?"

Physical therapists in America every day face Mrs. Smith. I've faced Mrs. Smith.

The above conversation is hard on Mrs. Smith and hard on physical therapists.

The new proposed Severity and Intensity Alternative Payment System is supposed to help physical therapists write notes that show how much Mrs. Smith needs her physical therapy.

The American Physical Therapy Association's (APTA) draft of the proposed Alternative Payment System for Physical Therapy Services describes how physical therapists can write notes that show Medical Necessity for Physical Therapy.

Medical Necessity is important when you need to justify your Plan of Care - for example if you apply the -KX modifier to attest that your patient needs PT in excess of the 2012 Cap of $1,880 for combined PT and Speech services.

Guccione et al in the September 2011 PT Journal described in detail their concept of how the Severity and Intensity model will work.

The Severity and Intensity model proposes a daily case rate to pay physical therapists' based on the mental effort and judgements we make during a patient visit.

The Severity and Intensity model will de-emphasize time as most valuable component of the physical therapist's service. The Severity and Intensity model will describe...

"...a broader conceptualization of work that emphasizes continuous examination and the multiple components of clinical decision making and patient care management will facilitate the determination of medical necessity and appropriateness of care."

Non-members of the APTA can read an overview of the Draft here.

MediFest in Florida in June 2012

Dear Medicare Part A and B providers:

First Coast Service Options (FCSO), your Medicare contractor in Florida, Puerto Rico, and U.S. Virgin Islands, invites you to register today for our upcoming premiere Medicare educational conference, Medifest, in Orlando, Florida June 5-7.

Medifest brings together Medicare experts, providers, and vendors to learn about what’s trending now in Medicare and how to lower your risk of payment recoupment and claim submission errors by improving your billing practices.

This year’s event offers more than 25 medical data-driven workshops and seminars often recommended by providers.

Here’s just some of the classes we are offering:

• Electronic health records incentive programs
• Avoiding roadblocks in billing Medicare secondary payer
• Billing global surgery
• Unraveling Medicare billing requirements:
• incident to,
• split/shared
• Using Medicare’s comparative billing report to determine if your utilization is higher than your peers Medical documentation and physician’s signature
• Selecting the proper E/M code
• Legislative update by the FHA

For a full list of course schedules click here

Our goal is to build a stronger Medicare community through education, so please join us for just one day or all three!

If you can’t make Orlando, FCSO is also coming to

• Panama City
• Jacksonville
• and Miami.

Stay tuned to our website at medicare.fcso.com for more information.

To learn more about Medifest, including registration fees, review our brochure.

Direct Access to Physical Therapists Can Reduce the Physician Shortage

Think physical therapists have it rough because our patients don't have direct access to our services?

State laws preventing direct access to physical therapist services still exist in four states:

• Alabama
• Indiana
• Mississippi and
• Oklahoma 

But, this recent article in The Atlantic by John Rowe, MD and professor at Columbia University exposes the plight of nurses and the political hypocrisy of physician organizations.

"...nurses are only permitted to practice independently to the full extent of their training and competence in 16 states and the District of Columbia. The remaining states (34) impose regulatory barriers that limit their scope of practice."

A 2010 Institute of Medicine (IOM) report on Advanced Registered Nurse Practicioners (ARNP) found...

"...the report concluded that properly trained APRNs can independently provide care primary care services as effectively as physicians."

But, according to Dr. Rowe, attempts by nurses to expand their scope of practice are blocked by physician organizations at the state level, such as...

• The American Medical Association
• The American Osteopathic Association
• The American Academy of Pediatrics
• The American Academy of Family Physicians

Social and cost pressures are growing to allow nurses greater decision-making authority. Physical therapists should also participate in this "flattening of the medical hierarchy".

But, physical therapists need to first practice more like primary care providers by providing basic screening care, like measuring blood pressure, according to this new study by Diane Jette and Dianne Jewell in the April Physical Therapy Journal.

Listen to PTTalker interview Dr. Jette here.

The problem is that physical therapists don't see themselves replacing physicians as primary care providers According to Drs. Jette and Jewell...

"...physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome."

Further, physicians cannot and perhaps should not be asked to provide all of these services.

Zeke Emanuel, MD, PhD argues in the May JAMA that we should "Shorten Medical Training by 30%":

"Years of training have been added (to the physicians' curriculum) without evidence that they enhance clinical skills or the quality of care.  

This waste adds to the financial burden of young physicians and increases health care costs.  

The average length of medical training could be reduced by about 30% without compromising physician competence or quality of care."

There will be no physician shortage in America - not if physical therapists can step up.

And I think we can.

Comments?

A Tale of Three Hospitals

"It was the best of times, it was the worst of times..."

So begins a story called A Tale of Two Cities by Charles Dickens. Its about the differing responses of two different nations to the revolutionary events and social upheaval of 1775. I'm going to tell a tale of three hospitals. You'll see why soon.

Today, in 2012, health care systems around the world, including the United States, are launching paradoxical, sometimes desperate, attempts to remain profitable and socially relevant to their patients.

The first hospital in my story is located in Valencia, Spain and is called Marina Salud Hospital de Dénia.

"Hospital de Denia is a rare example of a 100 percent paperless hospital and is a role model for what the hospital of the future should look like,” said Uwe Buddrus, CEO, Health Information Management Systems Society (HiMSS) Analytics Europe on May 7th, 2012.

All nurses and physicians at Hospital de Denia document their clinical notes online, making latest results available to clinicians instantly. Images are available online across the hospital network, physicians enter orders electronically and a clinical and business intelligence program enables staff to analyze care quality and efficiency.

Hospital de Denia enjoys the distinction of being the first HiMSS Stage 7 hospital in Spain and the second in Europe. HiMSS rates hospitals around the world, including the United States. HiMSS is headquartered in Chicago.

Hospitals that posses "interoperability" are expected to enable doctors and hospital administrators to improve the overall health of their local populations through innovative delivery techniques such as risk screening for people at risk for heart attacks and strokes.

Doctors can use the hospital database to reach out to "at-risk" individuals who, for example, may have missed their flu shot.

These interventions are only some of the most obvious tools the new electronic hospital will bring to a reformed health system that should produce better health outcomes at lower average costs going forward.

These innovative delivery techniques will be essential to financial success under Medicare Accountable Care Organizations (ACO) who will mandate measurement of population health outcomes.

The second hospital in my story is in Lakewood Ranch, Florida - a tony subdivision near Sarasota, Florida whose main distinction is the high net worth of its local inhabitants. Lakewood Ranch Regional Medical Center opened about 5 years ago despite the fact that at least three other major hospitals already served that area.

Reports of empty waiting rooms and empty parking lots have surrounded Lakewood Ranch since its opening day. Lakewood Ranch and its parent company, Universal Health Services, have implemented an electronic medical record at HiMSS Stage 3 (estimated). 

Smaller, non-teaching hospitals, like Lakewood Ranch, struggle with EMR adoption and the costs involved in achieving "interoperability", according to this April 2012 Health Affairs article.

The third hospital in my story is about one mile from my house here in Spain. It's a 1,645 bed super-hospital that has been under construction for two years and is expected to open in 2014. Like Spain's first HiMSS Stage 7 hospital in Valencia, is expected to be fully interoperable when it opens in two years.

Why one-third of hospitals will close by 2020 is the top post on KevinMD social media’s leading physician voice. 327 people have weighed in with their comments on whether or not David Houle and Jonathan Fleece's hypothesis is correct (Jonathan is partners with Michal Magidson, JD of Blalock/Walters in Sarasota who spoke to the Florida Physical Therapists in Private Practice in Orlando, Florida in August 2011).
Which of these three hospitals do you think will close by 2020?
It is the best of times to be a patient in one of these interconnected, interoperable super-hospitals.

However, it may be the worst of times to be the owner or the administrator of an unconnected hospital or private medical clinic in America's reforming health care system.

Stop High Physical Therapist Copayments in New York

The New York Physical Therapy Association (NYPTA) is calling on the state legislature to stop insurance companies from requiring patients to pay the higher “specialist" copay for physical therapy services.

Some patients are paying as much as $50 per visit while their insurance may only pay $10, or even nothing at all.

High “specialist” copays put physical therapy out of the financial reach of many patients, forcing them to forgo needed care or choose alternative options that drive up the cost of health care for everyone.

That's why I signed a petition to these legislators:

• The New York State Assembly,
• The New York State Senate, and
• Governor Andrew Cuomo.

Will you sign this petition?

Click here

Thanks!

Spanish Physical Therapists Solve "la Crisis" by Learning New Skills

Spain is experiencing 28% unemployment. In the 20-to-30 year age demographic unemployment is 50%. The Spanish people are in a "crisis" which seems to affect everyone and causes anger in some people. Many people want "the Government" to "do something".

Other people want the government to do less and spend less. There is much anxiety and uncertainty about the future. Many people have questions.

However, I'm happy to report, that many physical therapists (fisios) have decided to answer some of these questions for themselves.

Tim Richardson, PT teaches Spanish "Fisoterapeutas" the Epley Maneuver

This photo above is the SECOND class of about a dozen clinicians that I have taught in Vigo. I am training the Spanish "fisios" to treat dizziness and vertigo with Canalith Repositioning Maneuvers (Epley's).

Physical therapists in Spain have unrestricted direct access. They are licensed nationwide and their diploma is signed by the King of Spain, don Juan Carlos I (who just had hip revision surgery after a failed stabilization and prosthetic replacement in April 2012). He is now receiving physical therapy.

Most private practice physical therapists in Spain do not accept the government-sponsored social insurance (Medicare) because the rates are too low. Instead, their practices are cash-pay. With such high unemployment many patients don't have money and many physical therapists' practices are struggling.

Rather than complain, these private practice entrepreneurs are finding alternative sources of patient volume and revenue. That's where I come in. My new website with information for physical therapists' practices who want to learn the Epley's Maneuver is at www.FisioVertigo.com.

Despite the physician monopoly on socially-insured patient volume, the Spanish physical therapists are keen to learn new skills and apply them to the benefit of their patients. They are reaching out directly to patients using advertisements, sponsoring races and volunteering.

The attribute common to physical therapists whether in America or in Spain that I find is an optimism and a can-do attitude that says:

• "la Crisis" is temporary, good times will return again.
• whether treating patients or running clinics a positive mental attitude is a necessary requirement.
• Like our patients with disabling conditions who fight to better their condition, physical therapists look for answers rather than finding someone else to do the work.

The Spanish "fisios" I have taught and worked with are bright and hard-working. The Spanish people are in good hands.

Can We #SolvePT Medicare Audits Using Data Drilling to Fight Fraud?

Excellent webcast describes data-drilling for healthcare fraud by Thompson Reuters and XL Health.

Log-in here.

Complex, computer driven algorithms described in this webinar scan Medicare and Medicaid databases to look for "patterns of suspicious behavior".

For instance, the famous "ambulance trips to nowhere" are described here.

The take-home message is that fraudsters are finding it MORE difficult to use the healthcare system's inherent complexity to their advantage.

The data-drilling maps the healthcare providers referral patterns

What should be apparent after watching this webinar is that the typical physical therapist in private practice is NOT your typical fraudster.

Despite having a these documentation characteristics:

• low adoption rate of Electronic Health Records (EHR) of about 7%
• moderate rate of electronic documentation of 64%

...most physical therapists should not be on the list of "high-risk providers".

I wonder how we can #SolvePT when we're talking about Medicare Audits?