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.