Can EMRs Improve the Physical Therapy Experience?

"With great power comes great responsibility", quoted Heidi Jannenga, PT, MPT, ATC/L at the WebPT Evolve meeting in Orlando, Florida on October 18th, 2013.

Mrs. Jannenga was citing the explosive growth of the WebPT electronic medical record (EMR).  She mentioned the possibility that the WebPT user base at their current growth rate could actually overtake the number of physical therapists who are members in the American Physical Therapy Association.

Currently, WebPT has almost 27,000 therapist users who have generated over 38 million patient records since 2008.  WebPT claims that this is one of the largest repository of therapy outcome data in the world.

At the Evolve meeting in Orlando, Mrs. Jannenga and her husband Brad Jannenga, President, and CTO of WebPT had brought together a group of national-level physical therapist speakers. They spoke about Medicare compliance, internet marketing and key business metrics. The speakers delivered their own, original content.  They did not appear biased for or against any commercial EMR. 

I went to this meeting for two reasons: to prepare for an invited blogpost for the Technology Special Interest Group of the American Physical Therapy Association and as a user of WebPT trying to better understand the use of technology in the physical therapy clinic.

The meeting was pretty heady stuff, presented at the fabulous Peabody Hotel on International Drive in Orlando.  I would recommend anyone interested in learning about electronic medical records to attend this meeting.  WebPT opened the session for free to all interested parties.  Plus, they fed us dinner. 

This was the seventh Evolve meeting. The first one was held in Phoenix, AZ in October 2011. There have also been free Evolve meetings in Long Beach, CA, Palo Alto, CA, Chicago, IL, New York City, NY, Jersey City, NJ and Orlando, FL. WebPT will be holding more next year and will update their website with every new event.

To temper all the enthusiasm for electronic medical records however, I must show my readers some sobering facts that have recently come to light about the health information technology sector.

Do EMRs Add Value?
The idea that electronic patient notes will speed up therapy documentation by improving on handwritten notes just seems reasonable. But, new stories of expensive electronic medical record  cost overruns keep popping up in the media. To be fair, most of these stories are on the hospital side of the healthcare industry:

Adoption of expensive electronic medical record systems may hurt a hospital's bottom line, despite promises that the new systems will increase efficiencies and lower costs.  

Yet another hospital is reporting that the high cost of implementing a new EMR is having a negative effect, with Henry Ford Health System reporting its investment in Epic being a major factor in a 15 percent decrease in net income--from $62.9 million in 2011 to $53.1 million in 2012. From FierceEMR

Copy and Paste or 'Sloppy and Paste'?
There are additional concerns with the current generation of EMRs that allow essentially unrestricted copy-and-paste functionality between different dates of service. The clinician is trained to "document everything" which is almost too easy with computers. There is concern that patient information is not accurate.

According to a recent article in the journal of the American Health Information Management Association (AHIMA) called Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications

"Seventy-four to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text...  

It's become such a compliance and payment problem that the U.S. Department of Health and Human Services Secretary Kathleen Sebelius together with Attorney General Eric Holder wrote a letter last year to industry medical groups underscoring the seriousness of doctors "gaming the system, possibly to obtain payments to which they are not entitled."

'Note Bloat' Made EZ with EMRs
Several physicians complained about "note bloat", at an October 9th meeting of the College of Healthcare Information Management Executives (CHIME), where they said the content of the electronic note in the EMR lacked value because it was not "concise, complete and informational".

One example cited by Jim Venturella, CIO of the University of Pittsburgh Medical Center (UMPC), was a concerted effort by the  hospital to move physician documentation from paper to a Cerner EMR, between 2009 and 2012.

The new system produces 3.4 million notes a month in their inpatient EMR and 4 million notes in their ambulatory EMR. But in a survey of nearly 2,000 UPMC clinicians, less than half of respondents thought that the notes were valuable for patient care. (Healthcare IT News)

Is This the Year of the 'Great EMR Switch'?
More physicians and physical therapists are using EMRs.  Currently, the Centers for Disease Control and Prevention (CDC) estimates that 72% of practices in 2012 use an EMR, up from 54% in 2011. 

However, many providers are dissatisfied with their current EMRs and 17% of physicians are planning to switch their EHR within the next year according to the industry survey Black Book Rankings. 

The federal Meaningful Use mandates have created a 'one-size-fits-all' EMR model that contains too many features that too many providers don't want. 

Interestingly, specialty providers expressed the highest dissatisfaction with the current crop of EMR vendors due to the lack of customizable features.

Will specialty vendors, such as WebPT, survive the expected industry shake-out by narrowly focusing on the needs of therapists and their patients?  Can WebPT control and mitigate the abuses expected to arise from unrestricted copy-and-paste?   Will a WebPT note reduce 'note bloat'?

I suspect the market will shake out leaving the less fit EMRs in the dust. Many of the smaller EMR companies suffer from the same weaknesses that small physical therapy clinics and small businesses have faced recently - inadequate capitalization and a small user base.

The strength of the EMR industry is probably based on the same thing other industries are based on: sound balance sheets and a good cash flow.  Even great technology can't trump the ruthlessness of market forces.

According to surveys comprised from 16,000 EHR users and 550 EHR vendors by Black Book Market Research:

"Nine of 10 EMR industry insiders agree that the majority of EMR vendors currently implemented will fail to sustain operations by 2017.

Eight of ten EMR industry insiders predicted that well-funded, inventive small vendors that carve a niche in specialist sectors should have better foundations for viability than those who failed to resolve the fundamental flaws caused by being all things to all physicians."

I suspect WebPT will continue to gain market share and will remain a leader in the therapy EMR space.  They have a good product.  Their continued dominance will depend on their ability to remain responsive to the needs of their customers. 

Pop Quiz! Who can identify the quote Heidi used for her vision for WebPT at the beginning of this piece?

Do doctors of physical therapy need to call themselves 'Doctor'?

I wonder how the rest of the profession should view my physical therapist colleague who, having earned her Doctor of Physical Therapy (DPT) degree from a prestigious university, won't call herself doctor.

Not only will she not call herself doctor in the clinic, she asks people who DO call her doctor NOT to do so again.

I feel disappointed in her, not just because of her behavior, but for the reason she gives people, such as the front desk clerks in the physical therapy clinic, the equipment vendors and the patients when they initially call her doctor.

"I'm not a medical doctor, like some of the physicians I work with, and I don't feel confident that my expertise compares to their expertise - even though we each claim separate bodies of knowledge."

She is still young - only about four years out of her DPT degree. She works in a setting where she is in close contact with physicians - a physician-owned physical therapy clinic.

This physician-owned practice claims they provide collaborative care.  They emphasize the close communication among the physicians and the physical therapists.  From my colleague's behavior however, I suspect her workplace has impaired the development of her professional autonomy.  The American Physical Therapy Association's Vision 2020 Statement states:

Physical Therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.

Do doctors of physical therapy need to call themselves Doctor? 

I believe physical therapists should call themselves doctor if they have earned the right.  Please note, I have not earned the right to call myself Doctor.  Many other physical therapists have learned the specialized knowledge and skills to achieve great results without earning the DPT credential.  However, according to Randall Collins' 1979 book The Credentialed Society:

"In a credential society, such certifications may become more important than actual skills or abilities.  

In some cases, employers may require formal credentials, such as an advanced academic degree, for a job that can be done perfectly well by applying skills acquired through experience or informal study.  

This type of credentialism is common in white-collar jobs, which require workers to have difficult-to-measure skills such as critical thinking.  

Rather than measure or evaluate those skills directly, employers assume that anyone able to earn a credential must possess those skills."

'Skilled physical therapy' is a phrase that can provoke endless discussions among bloggers and commenters. There is a link between greater education and better results for patients.  More importantly, the DPT credential is, I think, an important step in the social legitimization of the physical therapist skill set. Physical therapists need to use the term Doctor to fully capture their investment in the time and money, not to mention for the benefit of the physical therapy profession as a whole.

Physical therapists do have one of those hard-to-measure skill set noted by Collins. So do physicians.  In hospitals, the physician credential is NOT optional.  The culture of medicine does not allow physicians to communicate with patients using their first names.

What go me thinking about my DPT colleague is an article called The Power of Professionalism in the September 2013 PT in Motion magazine (featured at APTA.org) whose print version arrived a couple weeks ago.  In the article, new graduate DPT Jean Miles says...

"What professionalism boils down to for me is being the strongest advocate for your patient that you possibly can be... Not that you have to be a DPT to be a strong patient advocate but I personally gained so much confidence..."

American society will need doctor-level professionals to manage the burgeoning rolls of newly-insured patients who have just become eligible for health insurance coverage on October 1st, 2013 under ObamaCare.

America's 800,000 physicians will face an increase in demand for their services - that, in some cases, they may be unable to deliver.

I first wrote about this in  Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals? in a November 2011 blogpost on PhysicalTherapyDiagnosis.com.  This post got a good response and a lot of traffic.

Every day, I read about non-physician providers stepping up to fill the demand in America for appropriate, high-quality services the patients need.  Cost and risk are both considered when society shifts tasks away from what physicians have traditionally done.  This article describes Physician Assistants providing basic care to rural and underserved communities.

Physical therapists can fill those roles for patients with chronic pain, sports injuries and other, low-risk conditions.  But first, society needs to understand and accept that the profession of physical therapists is a doctoring profession.  We should call ourselves 'Doctor'.

The American Physical Therapy Association (APTA) maintains a professionalism webpage which contains the core documents defining and describing professionalism in physical therapy.

I wonder if commenters to this blog can help me? 

What can I say to my colleague to encourage her to call herself Doctor?  How can I help her gain confidence so her patients and the physicians she works with can call her Doctor, too?

Cardiovascular Damage From Extreme Endurance Exercise

This post is a slight rest from policy and reimbursement issue for physical therapists on this blog.

I include this 21-minute video by cardiologist James O'Keefe called Cardiovascular Damage From Extreme Endurance Exercise because the implications are so surprising, to me, at least.

The evidence is starting to 'coalesce', in Dr. O'Keefe's words, that greater than 2-hour endurance races by older athletes may lead to permanent scarring and stretching of the myocardial (heart) muscle which can increase the incidence of arrhythmias, stoke and sudden death.

I have always tried to promote exercise to my patients with strictly orthopedic considerations. In other words, I've never considered an upper limit on the time or intensity of exercise from a cardiovascular standpoint. Again using Dr. O'Keefe's words, I've always subscribed to the 'more is better' paradigm. Perhaps now is time to reconsider my assumptions.

Since this is a controversial issue, it seems my assumptions are not mine alone - many athletes, coaches and laypersons probably subscribe to the 'more exercise is better' paradigm.



Sudden death is in the media lately.  Google is investigating how the new Google Glass can be used to properly treat athletes drop dead on the court or playing field.

Also, an August 8th post on the ADVANCE for Physical Therapy and Rehab Medicine website also discusses sudden death in younger athletes.

I've competed in over 50 triathlons, ultra-distance races and extreme endurance events in the last 20 years. In setting myself as an example I hope I've not done a disservice to my patients. I don't think so because my advice and example was based on the best evidence available at that time. Now, with new evidence, perhaps physical therapists (including me!) can incorporate better advice.

How to Build a Physical Therapist Network

Growing the Private Practice Physical Therapist Network

The Florida Physical Therapists in Private Practice (FLPTPP) bought a booth to grow the network at the 2013 Florida Workers Compensation Conference in Orlando August 19th -21st at the Orlando World Center Marriott hotel.

Left to right
Tim Richardson
Larry Feldman
Matt Serlo
Chris Mulvey
Armin Loges
not pictured: Ginger Hoang Le

We believe that this marquee event will be the ideal platform for us to promote our FLPTPP brand and begin the dialog for future business opportunities. Thousands of industry participants will be at the event and over 550 vendors. It has grown to be the largest event of its kind in the country.

As a group the FLPTPP are more attractive to prospective insurance companies as the cost associated with connecting with private practice physical therapists individually can be burdensome for insurance companies.

We have come up with a campaign for this booth and the web site called “It’s Personal. Every Time”. We believe this achieves our objectives as it differentiates the private practice physical therapists'  unique business model. It’s Personal because:

• We the owner/members are stake holders with a vested interest in mutual success…
• Many therapists left corporate employment that were impersonal…
• Third party administrators have hindered the case manager’s ability to communicate with the treating therapists…
• Unfair reimbursement can never lead to sufficient quality care…
• As business owners, we pay into this work comp system…
• With “US” it’s personal for the Employee, Employer, the nurse case manager, the insurance company and personal to our own self interests.

We hope you can join the FLPTPP and help us grow!

Private Practice Physical Therapists in Washington DC

The recent trip to Washington DC on the 23rd of July 2013 with the Private Practice Section (PPS Fly In) of the American Physical Therapy Association (APTA) to advocate for permanent repeal and replacement of the Medicare Sustainable Growth Rate (SGR) and overturn of the Therapy Cap.

Kerry (in this photo) also had the 'pleasure' of learning about Medicare Opt Out for physical therapists from us :)



From left to right:  Shamsah Shidi, PT,

Kerry L. Allen (Legislative Aide to Senator Bill Nelson)

Tim Richardson, PT

This next photo is in Congressman Vern Buchanan's office where Shane and I have met on many previous occasions.



Left to Right

Tim Richardson PT

Shamsah Shidi, PT

ShaneLieberman, (Legislative Director for Congressman Vern Buchanan)

Jack Front, PT

In this next photo, Gus Bilirakis had just informed of the pending vote by the House Energy and Commerce Committee on SGR reform. Bilirakis predicted there would be no opposition. Ultimately, the bill passed by unanimous vote, 51-0 on July 31 and would then move on to the full House.

Left to Right

Jack Front, PT

Congressman Gus Bilirakis

Shamsah Shidi, PT

Tim Richardson, PT

Sally Canfield of Senator Marco Rubio's office was present in 1997 when the original SGR formula was constructed. She resisted the temptation to wag her finger at her peers and politicos in Washington DC to say 'I told you so!'. Sally was probably the most well-informed and optimistic of all the congressional aides we spoke to that day.

Left to right:
Jack Front, PT
Shamsah Shidi, PT
Sally Canfield (Deputy Chief of Staff for Policy for Senator Marco Rubio
Tim Richardson, PT

I urge every physical therapist to leave your offices every now and then to get to know your legislators and advocate for physical therapists' patients. These people may control an important part of our future.

What has the American Physical Therapy Association done for you lately?

Patient stories...

Physical therapists hear these stories every day but the APTA is helping to put patient stories where they will do some good - in front of legislators who can determine your Medicare reimbursement.

The APTA coordinated a recent practice visit with the office of Federal legislator Vern Buchanan (R-Bradenton) on Tuesday, August 6th at a private physical therapy clinic in Bradenton, Florida. The following stories are a good example of what the legislator heard that day...

The 82-year old female patient gave a lucid, moving story about how her physical therapist had 'saved her life' by helping her remain living at home after a fall and a hip fracture. She mentioned she was already at the 'hard cap' of $3,700 in 2013 and didn't know how she could continue to pay for the services of her therapist even at the reduced frequency of one time per week.

The male patient, a retired veterinarian, told a very funny story of dislocating his shoulder by, believe it or not, walking his big dog. He was offered imaging and surgery by an orthopedic surgeon who owns therapy services. The patient said he wanted to think about these two options and, in the meantime, could he get a referral to physical therapy? That was three months ago and he now has full passive ROM. He is in no pain. He is also at the 'hard cap' but he credits his physical therapist with preventing what was, in his opinion, an unnecessary surgery.

Therapy Cap is top-of-mind for physical therapists because we deal with it every day but most legislators and their staff have many other responsibilities. Patient stories help make the recent Therapy Cap legislation REAL for members of the Congress by putting a human face on the problem.

The Medicare Access to Rehabilitation Services Act (HR 713) was recently introduced in the House of Representatives by Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA).  HR 713 would permanently repeal the $1,900 therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services.

We asked Congressman Buchanan to support HR 713 by attaching it to another bill that is gathering momentum in Washington DC.   The Medicare Physician Payment Innovation Act (HR 574), introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV) provides the following:

• repeal and replace the flawed Sustainable Growth Rate (SGR) formula.
• a clearly defined path to permanent Medicare payment reform.
• it includes a multi-year period of payment stability for Medicare providers.
• a stipulated annual payment rate increase of 0.5% to the Physician Fee Schedule.
• CMS will test and evaluate several alternative payment systems including the Alternative Payment System for therapy proposed by the American Physical Therapy Association. 

For the first time in many years, there is bipartisan support for repealing and replacing the SGR and fixing Medicare reimbursement for physical therapists via HR 574.  There is also a chance to fix the Therapy Cap by attaching HR 713.

To improve our chances you need to contact your legislators with your patient stories.   

A Unique Legislative Update

Guest posted by Adam Geril, DPT, MS, Owner - Geril Therapy

Being part of an organization of medical providers who have banded together to face the challenges of a recovering economy and changing healthcare environment has its advantages.

The Medical Business Leaders Network (MBLN) has been in existence since 2008. This network was formed to share cost savings and revenue producing ideas that spanned topics that included:

• tax law
• human resource management
• accounts payables
• accounts receivables
• marketing
• group purchasing

As this organization has grown to include multiple physician and medical professionals, we have found an audience amongst law makers. Given the recent completion of the Florida Legislative session we were able to secure a legislative update with Representative Dennis Baxley, and Charlie Stone. In order to make it interesting to the MBLN, a list of topics were sent to the Representatives prior to this meeting.

I am happy to say that each and every item on our list (that was compiled by the MBLN board on behalf of its members) was addressed.

Representative Baxley is the immediate past chair of the Health and Human Service Committee and currently chair’s the Judiciary committee. Charlie Stone is newly elected and now co-chairs the Judiciary committee along with the Senior House of Representative Dennis Baxley. Together a summary of the legislative changes that occurred this session was discussed. They included the following:

Why the Governor decided to remove power from the insurance commissioner to control rates in premium hikes. This turned out not to be the case and in fact was related to the affordable care act,

Expansion of scope of practice – Representative Baxley discussed the expansion of the optometrist’s practice specifically to prescribe certain medications. He reviewed how this was a hotly debated topic however laws were passed specifically to benefit the public. CS/CS/HB 239

Medical Negligence Actions – This prompted a personal discussion from Representative Baxley which centered about his fear of more physicians leaving practice in the state of Florida and more attorneys coming to practice in our state. This later progressed to a discussion on tort reform.

Medicaid Expansion – Representative Charlie stone stated that much was discussed however no decisions were made in this session and it will be discussed in more detail in the next session..

CS/HB 413 - Physical Therapy – Pertained specifically to the ability of ARNP’s to prescribe Physical Therapy.

CS/CS/SB 1094 Home Health Agencies - reduces the mandatory fine amount levied against HHAs that fail to file the quarterly report to AHCA from the current fine of $5,000 to a fine of $200 per day up to a maximum of $5,000 per quarter.

CS/CS/HB 1159 - Health Care Facilities – Specific to Nursing Homes – The bill specifically was amended to expedite the Certificate of Need review process if certain criteria were met. The meeting ended with an introduction to Jorge Bonilla running against Alan Grayson’s seat in the State House of Representatives and discussion with Paul Hawkes who is a lobbyist specifically as it relates to Tort Reform. This reform was to keep cases out of the legal system and make compensation fair and equitable to all parties involved.

To gain further valuable input this discussion evolved into scheduling a forum on tort reform in the state of Florida to be co-sponsored by Representative Dennis Baxley, Representative Charlie Stone, and the Medical Business leaders network.

For a full review of the 2013 summary from the Florida House of Representative please see this House of Representatives website.

The MBLN is a group of providers concerned with our collective stake in the health care market place. If you care to learn more about our organization, join, or participate in our upcoming Forum on Tort reform (this month) in the state of Florida.

Please check our website for updates and specifics including date, time, and place.

Sustainable Growth Rate Replacement On Sale at the #PPSFlyIn !

Like treasure-seekers at a sidewalk scavenger sale physical therapists can get a little excited about the potential for meaningful Medicare payment reform this summer. 

The flawed Sustainable Growth Rate (SGR) formula is on sale for a limited time only and the Congress can buy this dusty artifact from the 1997 Balanced Budget Act with new legislation in 2013.

The Medicare Physician Payment Innovation Act (HR 574) will provide a clearly defined path to payment reform as well as a period of payment stability necessary for physical therapist and physician practices to transition to an alternative payment system, reports Jerry Connolly from the American Physical Therapy Association Private Practice Section Advocacy Fly-In in Washington DC.

The cost to replace the SGR has decreased over the last three years because the 2009 Great Recession and ObamaCare have both driven down healthcare cost growth. The decrease in cost growth, in turn, changes the 10-year estimate to replace the SGR.  This estimate is calculated by the Congressional Budget Office which announced that the new price is $139 billion, down from $330 billion.

Only in Washington DC is $139 billion seen as cheap.  It's like finding an old vinyl copy of Led Zeppelin's 1971 Stairway to Heaven for $2!

The SGR is used to calculate physical therapists' Medicare payments.  The SGR has also been a big distraction for the Congress every year as provider organizations lobby to prevent ever bigger Medicare cuts. 

The 2014 adjustment is projected to be negative 24%!  Now that's cheap!

Why Physical Therapists Should Care About Interoperability

I just got back from the 2013 Florida Perspectives: Transforming Healthcare through Health Information Technology on Friday, July 19th, 3013 at the University of Central Florida, Lake Nona Medical Center in Orlando.

This program was put on by the Central and North Florida Health Information Management Systems Society (CNF-HIMSS).

Why should you care?

Physical therapists can help answer the problems of interoperability in healthcare which are far from solved. Nobody has all the answers yet - not policymakers, not administrators, not physicians and not even the technical gurus that help us keep our computers running.

Some of the challenges outlined by CNF-HIMSS are near-universal among healthcare workers and include the following:

• How should we train our new clinicians to use Electronic Medical Records in our daily work?
• How should we incorporate the legions of newly eligible patients under ObamaCare?
• How should Florida structure its new Medicaid program?
• Can the Florida legislature quickly reach agreement on important matters concerning healthcare?
• For that matter, can the Federal Congress reach agreement on important issues regarding funding?

Rich Rasmussen, the Vice President of Member Relations of the Florida Hospital Association got up about midway through the meeting and issued a call to action...

"We're all in this together!" he said, referring to the importance of adequate funding for state Medicaid recipients accessing care through the emergency room... 

"My healthcare and your healthcare costs are about $1,100 per year higher than they would otherwise be because of these uninsured patients."

What can physical therapists do? We can stay informed of the issues and support those that dovetail with issues important to physical therapists.

For instance, most of my readers know that in 2012 the Florida House of Representatives failed to support Governor Rick Scott's proposal to accept Federal funds for about 1.3 million state Medicaid recipients. The Florida Senate passed the Governor's plan but the House responded with a plan that would cover only about 100,000 Floridians. That still left over 1 million uninsured Florida residents!

Physical therapists, especially physical therapist private practice owners, would probably like very much for those 1 million Floridians to have access to physical therapy. Rich Rasmussen wants those people to have access to his hospitals.

When we can find this common ground with hospitals and other advocacy groups then physical therapists can really come together with a common voice to speak to our legislators. We can show our leader that we really are in this together.

Should Physical Therapists Abandon Direct Access? Vote 'No' on #APTArc20

A recent proposed motion in front of the American Physical Therapy Association (APTA) House of Delegates threatens to overturn 40 years of physical therapists' efforts to improve the professional standing of and patients' access to physical therapists.

The motion, RC20-13, moves to strike from the APTA agenda the pursuit of direct access to physical therapists' services.

Is abandoning direct access a bad idea? 

Here are six issues we should consider before we decide against RC20-13. I've referenced my facts so that you can determine for yourself why or why not RC20-13 is a bad idea:

1. Forty years of physical therapist advocacy for direct access carries a lot of precedence.  Two generations of physical therapists think direct access is a good idea, why change it now?
   
2. The biggest problem with RC20-13 (maybe this should go first?) - why does the APTA think direct access to physical therapists is synonymous with physician status under Medicare? You CAN have one without the other. Consider Nurse Practitioners. These professionals have a lot of decision making authority without physician status. In some states, NPs  can set up their own private practice.
3. In 2005 Medicare issued Publication 100-02 which was a MAJOR improvement in patient access by eliminating the face-to-face physician encounter for Medicare patients prior to physical therapy.  This was accomplished WITHOUT legislation and WITHOUT any change in physical therapist status under the Medicare program.  This policy was enacted during the period from 2001 to 2010 the APTA sought legislative solutions to achieve direct access.
4. Is physical therapist 'opt out' from Medicare more important than direct access?  Arbitrary Medicare coverage policies impair the concept of autonomous physical therapist practice which implies collaborative decision making between the patient and the physical therapist.
   
   Fewer than 1% of physicians eligible for Medicare Opt Out have chosen this alternative payment arrangement which results in negligible savings to the Medicare program.  Physical therapists in private practice might chose this arrangement at a higher rate - especially as Medicare reimbursements get squeezed.
   
5. The Patient Protection and Affordable Care Act (ObamaCare) coverage mandates kick in in 2014.  This will drive provider-based, innovative solutions due to changing payment incentives such as Medicare ACOs and Value Based Purchasing. 
   
   But, some changes have already occurred.  Primary care physicians have overtaken specialist physicians, such as neurosurgeons, as the main revenue drivers in some hospitals in 2012.  In a sample of over 100 hospitals, primary care physicians (family practice, general internal medicine and pediatrics) generated an average net revenue of $1,566,165 while specialists, such as neurosurgeons, generated only $1,424,917.
6. Hospitals and large healthcare organizations seem to be MORE effective at pushing scope of practice boundaries than the state-based professional associations in the state capitols. The professional associations mostly play an expensive, annual game of "Turf War" which is won by the association with the biggest war chest. 
   
   Large payers are also looking at their data and finding that direct access to physical therapists is good for business.  The Iowa Study of 63,000 employer-based insured people found that "...the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases...".  
   
   Large organizations, such as hospitals, insurers and employers, seem to be more accountable for the cost of care and seem to accept the value proposition illustrated by the Starbucks/Aetna collaborative.
   
   The value of non-physician primary care providers is very simple: its the money we make. Here is the median total annual compensation for the following providers in 2011:

Provider Type	Median Annual Compensation
General Internist	$215,689
Family Practitioner	$200,114
Nurse Practitioner	$93,977
Physician Assistant	$92,635
Physical Therapist	$81,110

Physical therapists can provide the best value for common, high-volume musculoskeletal conditions that nurses, PAs and physicians are less qualified to see.

If the APTA direct access agenda is predicated on physician status under Medicare then just drop that - don't drop direct access.

It's too soon to change strategy and there is too much at stake.  I urge the APTA House of Delegate to stay the course - continue to support direct access to physical therapists. 

You can join the Twitter conversation using this hashtag #APTARC20.

Is Disability an Identity?

Is there a culture of disability?  Do physical therapists' patients learn from each other ways of behavior that might reinforce the disabled mindset?

Before you answer 'Yes' or 'No' watch this video:



My favorite part is Andrew Soloman's inspiring message to parents at 11:46.

********

Do you still have questions about G-codes and Severity Modifiers?

My new book Bulletproof Expert Systems helps physical therapy managers sort through issues like these:

• Which patient self-report questionnaire should I choose?
• What is a validated patient self-report?
• How can I write goals for Medicare patients? 
• What is Medical Necessity and how do I demonstrate it in a note?
• What is Skilled Physical Therapy?

Stop reacting to every arbitrary change in Medicare rules and regulations - get answers to what Medicare REALLY wants from physical therapists. Click here.

RAC Activity Increasing, But Will They Hit Physical Therapists?

New data seems to show the Recovery Audit Contractor program is increasing its denial of claims by providers.  Physical therapist managers who bill the Medicare program are paying close attention to RACs even though small practice physical therapists' clinics have not been typically targeted by RACs.

Most of the RAC activity is targeted at the largest cost centers - that is, the hospital.

Beginning April 1st, however, small practice physical therapists that fall under the Medicare Part B $3,700 cap on physical and speech therapy will face RAC audits.  The RACs will  be performing both pre- and post-payment audits for the manual medical review (MMR) process.

RACs typically cite medical necessity as their number one reason for denial of claims. Altogether, the program corrected $5 billion in faulty Medicare payments since it began in October 2009, according to CMS.

Click through this image below for the April 2013 RAC results to date:



RAC result to date from the inception of the program in 2009

The American Physical Therapy Association (APTA) has a page of resources for physical therapists who want to comply with RAC requirements (membership required).  Check out this story at FierceHealthCare.com with additional links.

Tips to protect yourself from a RAC audit:

Educate yourself - the Florida Physical Therapists in Private Practice (FLPTPP.com) has a full day of educational programming May 18th, 2013 in Orlando, Florida geared towards recognition of risk and compliance with RAC audits, G-codes and the Manual Medical Review process.

Establish a compliance plan and conduct self-audits - hundreds of physical therapists have used this e-mail version of the Office of the Inspector General (OIG) Small Practice Compliance Plan to learn the steps - one of which is self audits:



Ensure follow-up - if you do get a RAC demand letter appoint one person in your office to immediately follow-up. You usually have a deadline, such as 30 days, to respond.

Meet the Presenters at Florida's Private Practice Physical Therapist Conference

Here is our distinguished line-up of presenters for the 3rd annual private practice conference in Orlando, Florida!  Sign up now at www.FLPTPP.com.

Nancy Beckley, MS, MBA, CHC is President at Nancy Beckley & Associates LLC. Ms. Beckley will present a Compliance Update for Medicare.

Pauline Franko, PT, CEEAA Owner at Encompass Consulting & Education, LLC, A physical therapist with over 30 years experience within the Medicare system. Ms. Franko will present Connecting the Dots: Creating the picture the reviewer needs to see.

Tim Richardson, PT is a physical therapist and book author. Tim will present "How to Effectively Use Outcomes Questionnaires for Federal Quality Reporting, Better Productivity and Better Outcomes"

Dimitrios Kostopolous, DPT, MD, PhD, DSc, ECS is a seasoned, widely published doctorate level physical therapist with a strong background in patient care. Dr. Kostopolous will present Myofascial Trigger Point Therapy & Strain Counter- Strain for Cervical Spine Pathology. This presentation-training is designed to have immediate clinical applications.

Konstantine Rizopoulos, DPT, MCMT, FABS Seasoned, multilingual doctoral level physical therapist with a strong background in patient care, management, public relations, marketing and teaching experience in the United States, South America, Europe and Africa. Dr. Rizopoulos will present Myofascial Trigger Point Therapy & Strain Counter- Strain for Cervical Spine Pathology. This presentation-training is designed to have immediate clinical applications.

Dr. Sean M. Wells is the owner and operator of Naples Personal Training, where he provides evidence-based physical therapy and personal training services. Dr. Wells will present "The One-Stop Rehabilitation and Fitness Center: The Future Structure of Physical Therapy Facilities"

Afonso G. Castro, MS, MSPT Afonso is originally from Rio de Janeiro, Brazil. Mr. Castro is a physical therapist practicing for several years in the fields of sports medicine, industrial rehab, acute care and neurofeedback. Mr. Castro will present "An Introduction to Neurofeedback".

Dr. Kathleen Swanick, DPT, MS, OCS Instructor, joined the faculty at FGCU in July of 2003 and currently serves as an instructor in the Physical Therapy Program. Dr. Swanick will present Use of Ultrasound Imaging (USI) In Physical Therapy.  The purpose of this course is to provide an overview of the application of ultrasound imaging in the field of physical therapy.

Dr.Arie Jacqueline Van Duijn, DPT, OCS, ACCE Instuctor and Academic Coordinator of Clinical Education, received her bachelor's degree in physical therapy in June of 1988 from the Academie voor Fysiotherapie in Leiden, The Netherlands, her post-professional doctor’s degree in physical therapy in April 2005 from the University of St. Augustine. Dr. Van Duijn will present Use of Ultrasound Imaging (USI) In Physical Therapy.  The purpose of this course is to provide an overview of the application of ultrasound imaging in the field of physical therapy.

Aaron LeBauer PT, DPT, LMBT is a Doctor of Physical Therapy and a Licensed Massage and Bodywork Therapist. He owns LeBauer Physical Therapy, which is a 100% cash based physical therapy practice in Greensboro, NC. Dr. LeBauer will present The Anatomy of a Cash Based Physical Therapy Practice.

New Florida state legislation threatens Physical Therapist Assistant education

"Hi, my name is Tim and I'm in the Senator's district. I'm calling today to ask the Senator to oppose Florida House Bill 1071."

"Ok", said the voice on the other end of the line. "What's your zip code?"

"34222", I said.

"Ok, got it. Thanks for calling. I'll make sure the Senator gets this", said the voice.

"Ok, thank you."  I said and I hung up.

Well, that was easy.  I also sent an e-mail to my Senator asking him to oppose Florida House Bill 1071 (CS/HB 1071).

According to the Florida Physical Therapy Association (FPTA), HB 1071 is legislation originally intended to address a number of glitches in current law affecting the accrediting of healthcare providers and hospitals. HB 1071 has passed the Florida House of Representatives on April 24th, 2013. Unfortunately the legislation was amended on the House floor prior to passage and language was added to the bill that is problematic for the Physical Therapist profession. The legislation will now be considered by the Florida Senate.

The problematic amendment adds NEW language to the Florida Physical Therapy Practice Act (licensure law) that addresses physical therapist assistant education and licensing requirements. Specifically the new language could allow for individuals who have graduated from schools NOT accredited by Commission on Accreditation for Physical Therapy Education (CAPTE) to sit for the PTA licensure exam!

This language is extremely problematic for a number of reasons and was added without consultation from FPTA. The proposed change would undermine the CAPTE accreditation currently required for all U.S. PT and PTA schools offering education and training of students seeking examination and licensure. If enacted, this language could open the floodgates for entities who are not experts in physical therapy, nor meet the quality standards of CAPTE to offer “PTA educational degrees” in the state of Florida.

The Florida Physical Therapy Association is strongly OPPOSED to this amendment.

Accrediting agencies like CAPTE hold programs to high standards that have been informed by multiple stakeholders inside and outside of the profession that guide quality student training - this is in the best interest of the public safety and patient care. Relaxing accreditation requirements could diminish the current levels of care protecting Floridians requiring physical therapy rehabilitative and habilitative care.

URGENT ACTION NEEED NOW!

Please click on the following internet link to send an email to your state senator in Tallahassee on this important issue. It’s easy and only takes a couple of minutes – the email is already prepared for you. The message to your state senator will urge him or her to OPPOSE CS/HB 1071 unless this problematic language is deleted from the bill. In addition, the message will ask them to oppose any amendments to SB 594 and SB 966 changing PTA educational accreditation:

CLICK HERE

Please be sure to follow up with a phone call to your state senator as well.

Physical Therapists and America's Disability System

Thanks to Adam Rufa, PT at ForwardThinkingPT.com for pointing our attention to the This American Life episode on March 22nd, 2013 called Trends With Benefits.  This episode is about disability in America.

Read Adam's excellent post about the 14 million Americans who don't show up for work every Monday morning but also don't show up in the official Federal unemployment numbers.

Rising disability is a 30-year American trend and 250,000 new Americans are applying for disability each month.

Perhaps the most backwards part about the disability system in America is there are only two ways off: you get so old that Social Security and Medicare take over or, you die.

Amazingly, the disability program doesn't provide physical therapy benefits to return you to your prior level of function.

Physical therapists should listen to this 57:26 minute podcast by reporter Chana Joffe-Walt for a very interesting tutorial on America's disability system.

Perhaps physical therapists  can understand our patients' perspective a little better if we understand the system we all live in.

New Speakers for the 2013 FLPTPP Conference in Orlando!

Cash Based Physical Therapy and the new Medicare Functional Reporting regulations are just two of the big topics the Florida Physical Therapists in Private Practice will tackle for you at the 3rd annual conference at the Lake Buena Vista Hilton on May 18th and 19th, 2013.

We'll have Nancy Beckley, President of Nancy Beckley & Associates LLC, discussing Medicare Compliance.

Pauline Franko of Encompass Consulting and Education will discuss new requirements for Functional Reporting using G-codes.

For private practice physical therapists interested in expanding their revenue base away from traditional Medicare and commercial insurance, Dr. Aaron LeBauer PT, DPT, LMBT will discuss how you can build a practice like his, which is 100% cash-based.

We will have an expo with many physical therapy vendors as well as a Saturday professional luncheon where you can continue your learning.

A clinical track will run concurrent with a business-oriented track. You should bring your Office Manager and staff to fully capture all the information at the 2013 FLPTPP conference. Get three of you signed up for only $575!

More programming is available at the Florida Physical Therapists in Private Practice (FLPTPP) web site.

We'll see you there!

Sign up here.

PIP Relief in 2013 for Florida Physical Therapists?

Physical therapists in Florida should continue the conversation with their patients and with their elected representatives if they expect the 2012 PIP anti-fraud law to change.

I was excited on Friday when I learned about the March 15th, 2013 decision by Circuit Judge Terry Lewis.   Judge Lewis granted the plaintiff's (a chiropractor) motion for a Temporary Injunction challenging the constitutionality of the 2012 PIP Act. This Act bars physical therapists, among other providers, from seeing auto accident victims without new, expensive and burdensome credentialing and licensing.  Full details are available at the Florida Physical Therapy Association web site.

According to attorney's familiar with this case, Judge Lewis' order will have a wide-reaching impact in Florida.  The following professions and conditions are specifically identified:

"1. Emergency Medical Condition - Judge Lewis' Order prohibits the use of an emergency medical condition as a prerequisite for payment of PIP benefits. This means that all Floridians will now benefit from the full $10,000 that they already have to pay for in PIP insurance coverage. This means that Chiropractic Physicians may primarily evaluate and treat those injured during motor vehicle crashes.  

2. Licensed Massage Therapists - Judge Lewis' Order prohibits the denial of payment for benefits for services provided by Licensed Massage Therapists.  

3. Acupuncture Physicians - Judge Lewis' Order prohibits the denial of payment for benefits for services provided by Acupuncture Physicians.  

4. Chiropractic Physicians - Judge Lewis' Order prohibits the denial of payment for benefits for services provided by Chiropractic Physicians.  

This lawsuit, challenging several provisions of the Florida Statutes, was filed in Leon County because that is where the State Agency in charge of enforcing these provisions resides.   

Importantly - this grant of Temporary Injunction applies throughout the entire State of Florida. Although some suggest that it might only apply in Leon County - that result makes little sense and would require that any statutory challenge be filed independently in every County - regardless of whether the State Agency charged with enforcing that statute resided in that that County.  

Although we certainly expect the State to appeal what we consider a well thought out, reasoned, and legally sufficient Judicial Order, the State's Appeal will be considered based upon an abuse of discretion - where the trial court would have had to abuse its discretion - something that will be difficult to prove given the large amount of data, briefing, and argument involved to date."

An open question is how does Judge Lewis' decision impact physical therapists in private practice? Specifically, can we now treat our auto accident patients without running afoul of the 2012 PIP Act?

Two more reasons I got excited last week were two bills introduced in the State Legislature: SB 594 and HB 709.  These bills exempt Federally-credentialed (Medicare) clinics from the 2012 PIP Act.  The Senate bill won unanimous approval, 8-0, by the Health Policy Committee on March 20th but the House bill has not moved yet.  According to Capitol insiders, the House bill needs to move now in order reach the Governor's desk by the end of session on May 3rd.

Further, these Capitol insiders don't expect Judge Lewis' Temporary Injunction to hold and physical therapists may not see relief in the 2013 legislative session.

"Keep up the pressure in your districts," they told me. "We've got a little momentum and some good media but we've still got a long ways to go."

Medicare Opt-Out for Physical Therapists

Representative Vern Buchanan
Washington D.C. Office
2104 Rayburn HOB
Washington, D.C. 20515
Phone: (202) 225-5015
Fax: (202) 226-0828

February 4th, 2013

Tim Richardson, PT

Re: A non-regulatory solution that will save Medicare $957,600 per year

Dear Rep. Buchanan,

Thank you for the opportunity to describe this proposal for a non-regulatory solution that may save Medicare hundreds of thousands and, perhaps, millions of dollars per year.

Medicare beneficiaries currently are not allowed to privately contract with physical therapists for the provision of physical therapy services in the United States. According to the American Physical Therapy Association (APTA):

“If a physical therapist accepts payment directly from a patient for a covered service under Medicare, he or she could be subject to federal investigation and financial and other penalties.”

However, Medicare beneficiaries are demanding more physical therapy services every year. Private practice physical therapy is growing faster even than the overall growth rate of the Medicare program (~8%).

From 2004 to 2009 private practice physical therapy grew at an average annual growth rate of 10%.3

However, many private practice physical therapists would prefer to see these patients without the administrative burden associated with the Medicare program. Title 42, Part 405 of the Code of Federal Regulations lists the regulations that permit a physician or practitioner to opt out of Medicare and enter into private contracts with Medicare beneficiaries, if specific requirements of these instructions are met.

Physical Therapists are not included on this list of physicians and non-physician practitioners who may opt-out of the Medicare program:

• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Certified nurse midwife
• Clinical psychologist
• Clinical social worker
• Registered dietitian
• Nutrition professional

Spending on therapy services, specifically physical therapy, is growing at an alarming rate from the perspective of government payment policy experts. Medicare spent nearly $6 billion dollars on all outpatient therapy in 2012 or about $1,173 for each Medicare beneficiary treated.

Reimbursement to physical therapists, however, is the opposite side of the spending coin. Many private practice owners see Medicare reimbursements as flat or declining and, with the uncertainty of the outcome of the Congress’ eminent Fiscal Cliff deliberations, would like to explore alternative business arrangements with their patients.

There are over 177,000 licensed physical therapists in the United States and an estimated 65,000 work in private practice settings. Private practices physical therapists are small businesspeople who would be the most likely practicioners to opt-out of the Medicare program. Many would prefer to seek private contracting arrangements with Medicare beneficiaries, if allowed to do so.

Recent, anecdotal reports of physical therapists in private, cash-pay practice place their annual revenues at about $150,000 for a full-time therapist treating non-Medicare patients. In contrast, a typical collections experience for a Medicare Physical Therapist in Private Practice (PTPP) is about $250,000 per year. However, much of this Medicare revenue goes to support administrative overhead, not to pay the therapist.

We can estimate Medicare’s cost savings if physical therapists are allowed to contract privately with Medicare beneficiaries. The aggregate Medicare spending for the PTPP outpatient setting in 2011 was $228 million. 

According to the Private Practice Section of the American Physical Therapy Association:

“...very few physicians have exercised this opt out affidavit. From 1998-2002, 2839 physicians, clinical psychologists, and other providers chose to opt-out. This represents 0.42 percent of the physicians and other providers eligible to opt-out.”

A conservative estimate of Medicare savings is $957,600 per year.

We understand this amount may seem trivial in the face of the enormous challenge before the Congress. However, there should be essentially no opposition or special interest group against a request from Representative Buchanan to the Centers for Medicare and Medicaid Services to include physical therapists in the list of physicians and non-physician practitioners who may opt-out of the Medicare program in Title 42, Part 405 of the Code of Federal Regulations.

To accomplish this change, we recommend that Section 1802(b)(5)(B) of the Social Security Act be amended as follows: Section 1802(b)(5)(B) (42 U.S.C. 1395a(b)(5)(C)) is amended by striking ``the term practitioner has the meaning given such term by section 1842(b)(18)(C)” and inserting “In this subparagraph, the term “practitioner” means an individual defined at section 1842(b)(18)(C) or an individual who is qualified as a physical therapist.”

The ultimate solution, or solutions, to our nation’s fiscal challenge may include multiple, moderate money-saving strategies. We hope that this proposal for saving Medicare money is one that Representative Buchanan can consider.

Thank you for your time and attention,

Tim Richardson, PT

'Blow Up' Physical Therapy Documentation, too

Hate G-codes? Think the Severity Modifier are a waste of your time? Dr. Halamka shares your pain:

"The way we document in medicine has grown up over decades for medical reasons, for billing, for medical-legal justification,” said Dr. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston. “You wind up with 17 pages of replicated and duplicated and challenging-to-read documentation.  

I propose we blow up the way we do documentation altogether and replace it with a Wikipedia-like structure.”

Dr. Halamka made these comments in the article EHRs: “Sloppy and paste” endures despite patient safety risk in American Medical News, February 4th, 2013. The article discusses rampant 'cloning' of patient notes in electronic medical records.

Dr. Halamka's statement references an article published in the February 2013 edition of Critical Care Medicine:

"The study examined 2,068 progress notes by 62 residents and 11 attending physicians of 135 intensive care unit patients in a medical center in Cleveland, using plagiarism detection software. 

The researchers found that more than four-fifths (82 percent) of the residents and three-fourths (74 percent) of the attendings' notes contained at least 20 percent of copied information." 

Dr. Halamka seems to go beyond the cloning issue - that could be solved by merely disabling the 'copy-and-paste' function in the EMR.  He wants to 'blow up' the whole documentation format which, I assume, includes SOAP.

SOAP has survived in medicine this long, I think, because medical notes are substantially more 'data-rich' than physical therapy notes. Another doctor could read the note and, despite its limitations, still glean sufficient data to make decisions. Physical therapy notes, however, are 'data-poor'.

But, 'cloning' is nothing new.  Physical therapists for years have handwritten 'meaningless drivel' on paper notes, according to Anthony Delitto, PhD, PT in Are Measures of Function and Disability Important in Low Back Care?

Any PT manager who has ever done a chart audit knows that many PT notes are repetitive and uninformative.  Why?  I'm not sure but I suspect that training and inertia are big factors.

Physical therapy documentation is way past its expiration date.  My students tell me they are still trained to write notes the way I was taught in 1990!  Don't believe that physical therapists are stuck on SOAP?  Read "What is a SOAP Note?" written in 2008 with over 17,000 page views!  SOAP notes were first described in 1968!

Physicians have adopted EMR software more quickly than physical therapists.  It is natural that they would use electronic  tools like 'copy-and-paste' to speed-up their work.  But, 'copy-and-paste' becomes 'sloppy-and-paste' when new technology catches up to our old, inefficient documentation format.

Many Electronic Medical Record (EMR) designers copied the SOAP format when they moved from paper to electronic to ease the burden on providers. Doctors could learn the new computer interface as long as they didn't also have to learn a new documentation format.

Physical therapists seem comfortable sticking with our traditional narrative-driven, SOAP-based format because it is comfortable, not because it is the right thing to do.

I would also like to see better ways of recording the patient experience and making better therapeutic decisions.  I think electronic communication tools can help providers do that.  But, medicine is substantially different from rehab.  Any electronic solution physicians adopt is unlikely to be ideal for therapists.

What ideas do readers of this blog have?  Video?  Photos?  Self-reports?

How can therapists collect better data?

If physical therapists don't come up with better ways of documenting then the government will do it for us.  You know what that gets us: G-codes and Severity Modifiers.

Spinal Fusions and Bone Graft Complications

Spinal Fusions and Bone Graft Complications
In the United States, a growing number of people suffer from debilitating back pain from degenerative diseases like arthritis. Spinal fusions and bone grafts – pieces of bone from the patient or donors or synthetic bone – are often used to treat back pain caused by slipped disks or damaged bones in the spine that can irritate nerves. In the United States, about 432,000 spinal fusions are done every year. A spinal fusion is a surgical procedure where surgeons take damaged bones in the spine called vertebrae and fuse them together to eliminate pain caused by irritated nerves.

As with any medical technology or procedure, however, spinal surgery and bone grafts do carry the risk of complications. If you are considering this type of surgery to relieve back pain, you may wish to discuss the risks and benefits with your doctor or consider alternative treatments for your back pain.

What is a Bone Graft?
Bone grafts are used to help bones heal and can be pieces of bone taken from a patient's own body or from a donor. The majority of bone grafts – 84 percent – are used in spinal fusions. One of the most recent advances in back surgery is the invention of synthetic bone grafts known as bone morphogenetic proteins (BMPs). One type of BMP is manufactured by Medtronic under the brand name INFUSE. It is approved by the Food and Drug Administration (FDA) for limited use in specific types of spinal surgery.
These proteins are powerful hormones that encourage new bone to grow faster and are used with titanium hardware that stabilizes the vertebrae as the bone grows. Using BMP eliminates the need for painful surgeries to harvest bone in the patient or donated bone that may harbor infection or disease.

The Risks of Spinal Fusion Surgery
All forms of surgery have their complications, and spinal fusion is no different. Some of the general surgical complications include blood clots, infection, lung problems and anesthesia complications.
Spinal fusion can also lead to loss of mobility in the spine because the vertebrae are fused together, making this option unattractive to younger, active people. The disc surrounding the fused vertebrae may also deteriorate quicker because of extra stress, and more surgeries will be needed to repair these discs.


Some specific spinal fusion complications include:

• Hardware fracture.Sometimes the hardware used to support the bones while they heal can break; this requires surgery to remove.
• Implant migration. The implant can move from where it was placed by the surgeon; this can cause damage to the spine or blood vessels.
• Spinal cord injury.
• Persistent pain.
• Sexual dysfunction.
• "Failed back surgery syndrome." There is a 20 percent risk that spinal fusion will not relieve back pain. Also, some vertebrae may not fuse together properly and can create what is called pseudoarthritis.

In addition to these complications, the new synthetic bone grafts used in spinal fusion also come with their own problems. In 2011, Dr. Eugene Carragee published a review revealing that BMP products like INFUSE have a 43 percent higher complication rate than previously published. Complications like crippling back and leg pain, and ectopic bone formation (unwanted bone in the spinal canal) have caused a number of individuals to file lawsuits against Medtronic claiming the INFUSE bone graft is a faulty product.

Non-Surgical Alternatives to Spinal Fusion Surgery
Before undertaking spinal fusion surgery, there are some alternatives that you might wish to explore when talking with your doctor. According to Dr. Stewart G. Eidelson, less than 5 percent of people with a spinal disorder require surgery.

Spinal stenosis and degenerative back problems can be treated non-surgically with treatments, including:

• Medication that can reduce inflammation, muscle spasms and pain. Though, these are not without side effects.
• Epidural injections can deliver steroids to the space surrounding nerve roots and help reduce pain in the arms or legs.
• Physical therapy is also effective in managing back pain. A combination of inactive therapy – ice packs, ultrasound, massage and electric stimulation – and therapeutic exercises, including stretching and exercises to strengthen muscles and make them more flexible, may be prescribed.

If your doctor recommends spinal fusion surgery for your low back pain, you should get a second opinion if you are concerned about the possible risks. As always, make sure you discuss all options with your doctor, along with the benefits and risks.

Michelle Y. Llamas is a content writer for Drugwatch.com. She educates consumers about dangerous drugs and defective medical devices.

Reimbursement for G-codes?

We're using G-codes as a stepping-stone to an outcomes-based reimbursement system, aren't we?" asked my client today. Jami is a nurse running a occupational theapy hand clinic. Jami is preparing her office for mandatory G-code reporting on July 1st, 2013.

"No", I replied. "We're just reporting our compliance.  We're not measuring function."

"Well, we showing we're getting the patient better, aren't we?", replied Jani.

"No, not really", I replied. I paused in the conversation, not sure how I could quickly explain the statistical concepts needed to understand why Functional Reporting using G-codes and Severity Modifiers could not lead physical therapists to true outcomes reporting.

"What a bust for FOTO", I thought.  Focus on Therapeutic Outcomes had the Cadillac risk-adjusted outcomes measurement system for therapy services in the world and the US government took a pass on them and chose G-codes and Severity Modifiers instead.

Of course, FOTO costs $250 for set-up and $25 per month per therapist.  And, they own the outcomes marketplace.  There is essentially no competition.  I could just imagine the hue and cry if the government granted a de facto monopoly to FOTO and mandated that every therapist measure patient outcomes using a risk-adjusted measurement scale, like FOTO.

"We know how to measure outcomes!", Jami said, eagerly. "We're using the DASH already!"

"I use the DASH, too", I explained.  "And, that's what Medicare wants.  But, a discharge score on the DASH that is, say. 20-points better than the initial score can't be used to compare your clinic to mine."

There are four levels of measurement (adapted from Jewell):

Level of Measurement	Example
Nominal	apple, orange, pear
Ordinal	happy/sad OR hot/warm/cold OR MMT grades
Interval	temperature, height, weight
Ratio	blood pressure, speed and distance

There is not a fixed interval between values such as "happy" or "sad" or, for that matter, the rank ordered scales of the OPTIMAL, the DASH or any of the other paper questionnaires.

These rank orderings are not numbers but are indicators for modifying words. The OPTIMAL uses words for values such as 2 = "little difficulty".

The lack of a fixed interval between these values means that mathmatical functions cannot be performed on them. The difference between a "1" and a "2" is not the same as the difference between a "2" and a "3". We can't add, subtract, multiply or divide OPTIMAL, DASH or any of the other self-report scales becuse they lack intervals.

The interval level of measurement has a fixed interval between each number which allows addition and subtraction. A 10-point change in temperature from ninety degrees to eighty degrees is the same ten point change from fifty to forty degrees.

The ratio level of measurement has a known zero point which indicates the absence of the chacteristic being measured. Zero miles per hour means the car is standing still. Ratio data can be manipulated like interval data with addition and subtraction. Also, ratio data can be manipulated with multiplication and division.

All of these techniques are being used to convert self-report scale data from raw scores to the new Medicare Severity Modifier scale.

That is probably fine for simple reporting to prove to Medicare that physical therapists can report functional scores.

But, when Medicare starts paying one therapist more money for better outcomes based on functional data they had better create something better than G-codes and the Severity Modifiers.

Nurse Practitioners Seek More Authority in Florida

Ryan Grella, a physical therapist from the Tampa Bay area has brought to light this new article in the Tampa Bay Times: Nurse Practitioners Seek More Authority in Florida.

Ryan and I and several of our friends, peers and professional colleagues have discussions on Direct Access to Physical Therapy all the time. Here is Ryan's Letter to the Editor of the Tampa Bay Times:

"The nurse practitioner story in the Tampa Bay Times sheds further light on Florida’s antiquated healthcare laws, which are driven in part by highly funded medical organizations as well as physician lawmakers who have inherent conflicts of interest.  

The citizens of Florida deserve access to high quality evidence-based healthcare devoid of unnecessary rules and regulations.  

Presently anyone in this state can receive care from a speech therapist, occupational therapist, massage therapist, or personal trainer without physician oversight. Yet, state licensed doctors of physical therapy must refer their patients to a physician after 21 days.  

This provision exists under the veil of public safety despite overwhelming evidence of physical therapist competence and direct savings to the patient. The Florida Medical Association (FMA) is adamantly opposed to any legislation that would remove the 21-day provision.  

Should we be surprised?Apparently not.  You wouldn't expect the FMA to object to anything that changes the status quo.  

Physicians are now competitors for the patient’s valuable healthcare dollars. At some point however, nurses and physical therapists must ask the FMA and lawmakers, is it about the patient, or is it about the dollar?"
 

Ryan Grella, Physical Therapist

New Quality Reporting Mandates Affect Physical Therapists and Hospitals

Hospitals are worried that their Electronic Medical Records cannot adequately generate the necessary data to fully comply with burdensome quality reporting mandates in 2013. Read more here.

This is Only a Test...

Functional Reporting for Medicare in 2013 is only a test.

If Functional Reporting were true outcomes reporting physical therapists would need to use risk-adjusted outcomes measures, not paper questionnaires.

Instead of true outcomes reporting, physical therapists are only being assessed on our ability to report patient functional status via the claims system.

The Centers for Medicare and Medicaid (CMS) states in Transmittal 165 that this new system is designed to assess the ability of physical therapists to report patient functional status via claims forms, like the CMS 1500.

A trusted source at the APTA states that Medicare just wants physical therapists to show that we are using functional status measures and that we can predict change.

However, the change scores are not valid indicators of change.  And, the functional status scores can't be used as valid indicators of patient function. They can't even be used to compare my outcomes to your outcomes.

According to Jewell (p.154), "These (ordinal scores) are not measured with numbers, but are indicated with modifying words.  The absence of a known distance between each level of these scales means that mathematical functions cannot be performed directly with the measure."

Ordinal data, such as reported on the OPTIMAL scale, Oswestry, LEFS, SPADI, ABC, DHI, Berg etc. can't be used to do addition and subtraction, multiplication or division.

However, the new Medicare Severity Scale require physical therapists to convert the raw scale scores to percentage categories corresponding to modifiers that can be appended to the CMS 1500 paper or electronic claim form.

Medicare Severity Scale for G-code Modifiers

When this important detail was pointed out to me, I was initially surprised and disappointed.  I originally saw Functional Reporting as a stepping stone to true outcomes reporting.

Not the case, says my trusted source.  "Don't get caught up in the math," he said, "The numbers aren't important", he implied.

"Functional Reporting is here to stay but you're not measuring true outcomes and you shouldn't expect this data to be used to improve the reimbursement situation for physical therapists."

Like I said, this is only a test.