"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

Saturday, September 29, 2012

Price, not More Visits, Drives Cost Increases in Healthcare

Why should you care?

Commercial health care costs are going up - does it matter whether price or patient volume is to blame?

Yes. The Town Hall meeting at the recent Florida Physical Therapy Association (FPTA) meeting included discussion about Copayment reform legislation in Florida.

Some voices in the Town Hall argued that Copayment reform legislation in Florida is not necessary since rising physical therapy utilization indicates there are no barriers to patient access to physical therapists.

Increasing health care costs, to employers via premiums and to employees in the form of rising Copayments, reduce access to physical therapist services.

Do we want to live in an America where only the rich or the employed have access to physical therapist services?

The findings of the Health Care Cost Institute from September 2012 found that
"... price growth for outpatient facilities and professional procedures remained higher than (patient volume) utilization growth.".
The prices paid were the primary drivers of health care spending in 2011.

According to a September 25th Washington Post article:
"Employers typically have tried to control costs by reducing the volume of care delivered, whether that means higher co-pays for doctor visits or using prevention to catch costly diseases earlier."
Copayment reform for physical therapy patients was a "slam dunk" in Kentucky, South Dakota and New Jersey in 2011 and 2012.

Other state physical therapy associations have not seen the same rapid success with Copayment reform. There is not even uniform agreement that Copayment reform is necessary for patients. Florida is one example where there is disagreement.

Some other opponents of Copayment reform at the recent Town Hall meeting in Daytona Beach spoke out and suggested that insurance companies would "get mad" at the FPTA if we, as an organization, supported Copayment reform.

These opponents, who are physical therapists, are supporting the insurance companies because the insurance companies support them.

When insurance companies set the political agenda for the FPTA we are allowing them to put profits before patients. We need Copayment reform to protect patients. From the Post article:
"Some economists have argued that government regulation is exactly what we need to slow price growth and ensure patient access.
Maryland is the only state in the USA where the government sets the rates that hospitals can charge insurance companies. 
Maryland's hospitals from 1977 to 2009 experienced the lowest cumulative increase in cost per adjusted admission of any state in the nation. And private insurers pay the same rates as public insurers.
All states except Maryland gravitated away from those models, as states have looked for more competition and less regulation in health-care markets."
Consumers will continue to need physical therapy services and employers will continue to buy lower priced health care with lower premiums for their employees. This means higher Copayments.

This problem wont go away and it can't be solved through "free market" methods.

States need legislative reform that lowers Copayments for patients.

Monday, September 17, 2012

Are Physical Therapy Students Risk Averse?

Do physical therapy students always choose the safe alternative?

Does $100,000 in debt cause students to vote for the status quo?

Do physical therapists and students feel so much anxiety over health care reform that they prefer to vote for short-run self-interests over long-run investments?

Outcomes measurement linked to physical therapist reimbursement was the subject of the 2012 Oxford Debate at the Florida Physical Therapy Association Meeting (FPTA) in Daytona Beach. The students and physical therapists in the room - about 400 - mainly voted against using these measures for payment.

I question if students, in these changing times, are prepared to put the interests of their patients and their profession ahead of their own interests. I can't really blame them. I was a student once, too. The future is uncertain and scary.

This student-led decision was reminiscent of the American Physical Therapy Association's (APTA) 2011 Annual Conference in Washington DC when a student-dominated audience voted against Clinical Decision Rules.

Oxford Debates pit two teams arguing contrary positions. Each team "wins" by persuading the audience to cheer, make noise or physically move from one side of the room to the other. The side with the most supporters wins the debate. Most Oxford Debates handle serious topics in a fun environment. Drinks are usually served.

This convention was well-attended by students, many of them from the University of St. Augustine. The student-dominated audience split about 60/40 against using patient outcomes to reward physical therapists.

Inadequate risk adjustment seemed to be the main reason outcome measures should not be used, according to the speakers and the audience. In other words, the measure would ONLY capture the outcome of care which might depend on factors other than the therapists' effort and skill.

For instance, if the patient does not do their home exercise program they will tend to have worse outcomes than if they do their exercises. Older people with multiple diseases will usually have worse outcome scores at baseline and at follow-up than younger people without disease.

We've recently heard similar arguments in the Chicago teachers' strike when school teachers objected to being paid based on the standardized test scores (outcomes) of their students. The teachers argued that many factors that affect test scores are beyond their control. Paying teachers based on test scores was unfair since many of the determinants of teacher performance happened outside of the classroom.

A physical therapy student at the Oxford Debate noted that the most important determinants of health also occur outside the physical therapy clinic. These determinants are things like the following:
  • family and social support 
  • a positive outlook 
  • educational level 
  • addictive behaviors, such as cigarette smoking 
  • level of activity
Young people are typically more tolerant of risk, according to standard economic thought. They have more years to make up any financial loss so they're supposed to be more willing to accept risk.

However, I think these students' behavior is rational.

Instead of pushing physical therapists and students to accept a reimbursement system that puts us at risk let's design a system that lets us think about patient care rather than worry about money.

What do you think?

Friday, September 14, 2012

Exercise Prevents Falls in Older Adults but Cognitive Behavioral Therapy Does Not

Older adults falling down at home and elsewhere is a growing problem in the United States. About 30% of older people fall in a year.

An update of a 2009 Cochrane Review of the effectiveness of a falls reduction programs found that exercise and home safety interventions prevent falls in older adults.

The investigators assessed 159 randomized trials of fall prevention interventions with nearly 80,000 participants aged 60 and older.

Among the other interventions that helped reduce the rate of falls or risk for falls:

  • Multifactorial interventions, including individualized risk assessment 
  • Tai chi 
  • Pacemakers, in patients with carotid sinus hypersensitivity 
  • First eye cataract surgery in women 
  • Gradual withdrawal of psychotropic drugs 
  • Changes in prescribing behavior by primary care physicians 
  • An anti-slip shoe device in icy conditions 

Some of the interventions that did not have an effect include:

  • Vitamin D supplementation in people with normal vitamin D levels 
  • Patient education alone 
  • Cognitive-behavioral therapy
(reprinted from JournalWatch, Massachusetts Medical Society)

Thursday, September 13, 2012

Town Hall Meeting Provokes Excitement

The Town Hall at 5:30pm on Thursday, September 13, 2012 at the FPTA Annual Conference & Assembly of Representatives in Daytona Beach was interesting, exiting and invigorating.

We heard many passionate, intelligent and involved physical therapists voicing their opinions.

The differences of opinion were sharp but friendly. The divide spun on the future direction of the FPTA advocacy resources.

In other words, we do have some political and social capital but which way do we spend it?

  • Copayment legislation? 
  • Term Protection? 
  • PIP legislation?

Tomorrow, I will present How to Open a Private Practice in Line with APTA's Vision 2020 with Adam Geril, DPT and Adam Woods, a banker.

My contribution will be Using Functional Outcome Questionnaires to Get Medicare Compliance.

I hope you can make it.

Wednesday, September 12, 2012

Why We Have Brains

Neuroscientist Daniel Wopert suggests that human brains evolved for ONE REASON ONLY.

To control movement:


Not thinking, not reasoning, not tool-making.


Dr. Wolpert's findings may have implications for physical therapists.

If our human brain needed to evolve in order to control movement, then restoration of movement may take priority over classic, medical approaches. The medical paradigm attempts to "cure" the patient or the pathology.

For example, spinal pain patients are often told that their bulging disc is the cause of their lower back pain. They may then be told that bending, lifting or twisting their back causes further disc bulging and pain. Their typical response is to further limit their activities, especially bending, lifting and twisting.

Perhaps movement therapy should begin before the "cure" or in place of the "cure".

Watch Dr. Wolpert's video and add your comments below this post. Thanks.


Tuesday, September 11, 2012

Is there a physician shortage in America?

Uwe Reinhardt is an economics professor at Princeton and former keynote speaker at the American Physical Therapy Association (APTA) Annual Conference sometime back in the 1990's.

Professor Reinhardt pokes holes in the "doom-and-gloom" scenario of a pending physician shortage in America and I agree.

I wrote about this fallacy on November 28th, 2011 in Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals?


I believe economic necessity will intervene as public policymakers and private payers join forces to push physical therapists into direct access roles for musculoskeletal conditions.

The time is right now. According to Professor Reinhardt:
"...the suspected physician shortage now imputed by critics of the Affordable Care Act may actually drive our health system into more efficient medical practice.
Step No. 1 in that direction, of course, would be to lighten the enormous administrative load now heaped by our health insurance system onto physicians devoted to rendering patient care."
Delegating high-volume spinal pain, sports injuries and many chronic pain patients to physical therapists would relieve much of the physician workload and eliminate the physician shortage.

Thursday, September 6, 2012

Taking Routine Blood Pressures in the Physical Therapy Clinic

Physical therapists should be taking routine blood pressures in the physical therapy clinic.

We have evidence that physical therapists don't routinely assess blood pressure from Jette and Jewell's April 2012 study in Physical Therapy Journal.

Only 11% of 2,544 physical therapists in all settings measured and followed-up with blood pressure. Every time your patient comes in you, or a member of your staff, should take and record their blood pressure.

The Centers' for Disease Control and Prevention (CDC) reported today that over one-half of American's have hypertension defined as
"...average systolic blood pressure (SBP) greater than 140 mmHg or an average diastolic blood pressure (DBP) greater than 90 mmHg, or currently using blood pressure (BP) lowering medication."
Over one-third of Americans with hypertension were unaware of their problem and 90% of them had a usual source of care - that is, they had a doctor.

According to the CDC report: Vital Signs: Awareness and Treatment of Uncontrolled Hypertension Among Adults — United States, 2003–2010
"Nearly 90% of U.S. adults with uncontrolled hypertension have a usual source of health care and insurance, representing a missed opportunity for hypertension control. 
Improved hypertension control will require an expanded effort and an increased focus on blood pressure from health-care systems, clinicians, and individuals."
This is a major opportunity for physical therapists to assume an increased role in the care of Americans.

Physical therapists can position themselves as primary care providers by providing increased blood pressure monitoring and referral. Primary care providers, physicians and otherwise, will be an important workforce component for hospital systems participating as Accountable Care Organizations (ACO) within the Medicare Shared Savings Program.

Finally, to prevent a Medicare Audit a physical therapist can document routine blood pressure measure before, during and after exercise can show Skilled Physical Therapy.

"Skilled Physical Therapy" means that your service normally wouldn't be provided by a lesser trained provider, such as a massage therapist or athletic trainer.

Physical therapists work on medically complex patients where safety is a key concern. We know that 7% to 12% of individuals experience an adverse response to exercise. Adverse response is defined as:
"...an exercise-induced change that worsens a risk factor (such as BP) beyond measurement error and expected day-to-day variation."
Physicians probably cannot detect these individuals reliably. Physical therapists could measure blood pressure changes during and after and on multiple sessions of exercise. Adverse changes could provide the physical therapist with cues that could indicate a change in the Plan of Care or referral.

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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 .

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