Is the United States Government Biased Against Private Practice Physical Therapists?

I've thought about this subject for several months - ever since March 2010 when MedPAC delivered its annual Report to the Congress: Medicare Payment Policy.

Now comes this recent article from The Annals of Internal Medicine, picked up on the Evidence in Motion blog, that verifies the implications of the MedPAC report and my suspicions.

The report was black and white evidence that our government is biased against small healthcare providers - where 70% of American healthcare takes place!

Medicare "guess-timates" on adjustments to the Physician Fee Schedule based on access to capital markets for selected healthcare sectors.

"Substantial increases in the number of providers may suggest that payments are more than adequate and could raise concerns about the value of the services being furnished...

The volume of services can be an indirect indicator of beneficiary access to services...

Volume is also an indicator of payment adequacy; an increase in volume beyond that expected for the increase in the number of beneficiaries could suggest that Medicare’s payment rates are too high."

Providers’ access to capital

"Access to capital is necessary for providers to maintain and modernize their facilities and capabilities for patient care.
Widespread inability to access capital throughout a sector might in part reflect on the adequacy of Medicare payments (or, in some cases, even on the expectation of changes in the adequacy of Medicare payments).
However, access to capital may not be a useful indicator of the adequacy of Medicare payments when the sector has little need for large capital investments, when providers derive most of their payments from other payers or other lines of business, or when conditions in the credit markets are extreme."

Guess what? Small clinics like mine and yours DON'T have access to the capital markets! These days we may not even have access to bank lines-of-credit anymore!

The MedPAC report implies that only large firms with scale economies, access to capital markets and administrative staff that can maximize revenue and compliance will succeed in the future.

The Annals article, titled The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges was written by physicians with close ties to the present administration. Their opinion echoed the MedPAC report:

"The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.
The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience."

No rebuttal was printed by the Annals editors but many online readers voiced vigorous opposition to the politically positive tone of the Annals article.

Physical Therapists and the Multiple Procedures Payment Reduction Policy (MPPR)

The recent, proposed Multiple Procedure Payment Reduction (MPPR), is just the end result of policy discussions at high levels that those of us in private practice can only react to - we usually don't get a voice in these decisions.

Hopefully, many of us wrote letters to the head of the Centers for Medicare Services, Dr. Donald Berwick, pointing out that the projected 13% revenue "savings" will be disasterous for private practice physical therapists and their patients.

Here is a copy of the letter I sent.  The comment period closed August 24th and we'll learn the final adjudication November 1, 2010.

Take Home Message

I don't think the future of physical therapy belongs just to large firms - private practice physical therapists can still effectively compete.

The Annals authors, however, do not believe managing future change is possible in small practices:

"Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."

They appear to have reached the conclusion already that small businesses in medicine and physical therapy will go the way of the dinosaur.

In order to prevent our own extinction we will need to gain control of the one thing that we have that the government wants - our patient data. We need to control not just outcomes data but also baseline data on patient characteristics that affect outcome. Also, we need to show that our decisions on patient care are BETTER than physicians decisions.

Why are physicians referring patients to us? We should be referring patients to them! We should be the point of entry!

But, to gain control of our data we will need better systems for managing data.  Not just Electronic Medical Records (EMR). And not just Clinical Decision Support (CDS) systems, either.

We'll need a marriage of EMR and CDS that will improvement the process of care - as delivered by physical therapists.  We'll need to show that ONE care process in particular: care delivered hands-on by physical therapists DOES lead to better outcomes.

While outcomes are difficult to measure, process measures are much easier. I have not been especially happy with many burdensome process measures in physical therapy but hands-on care is a "no-brainer".

This new study in the August 2010 Physical Therapy Journal is just the second published article showing that PT process measures improve patient outcomes.

What to Do?

Ask your EMR vendor about integrated decision support - what are you doing with your data?  If you don't have an EMR you can still use pen-and-paper decision support tools - usually paper templates - that can be stored in the patients' chart.

These templates can be set up to predict the duration, frequency, total cost and expected outcome. Baseline co-factors can alert us ahead of time to those patients at risk for "failing" in physical therapy - these are the "outliers" that Medicare so desperately wants to identify.

Some "outliers" will need more therapy, some will need referral to psychological screening and some will need surgery.

I hope we can convince the Congress soon that the most efficient setting for physical therapists to serve Americans in this way is often the small, outpatient physical therapy office.

How Can I "Sell" the DOTPA 17-page Physical Therapy Evaluation to my Friends and Peers?

I've a confession to make...

I once tried to go to work for Stryker Corp. This was back in 2005, before I decided to make the big commitment to private practice physical therapy.

Stryker Corp. are the folks who make prosthetic hips, joint cement, screws and locking systems for joint fusions. Their customers are orthopedic and neurosurgeons who have among the most expensive pens in all of medicine.

My Stryker contact made me take a test called the StengthsFinder Test. The point of the test was to identify the strengths of those people who would make a killer salesperson:

• Achiever
• Competition
• Interpersonal
• Stimulator
• Persuasion

Although neither Stryker (nor Gallup) will reveal their criteria for hire I believe these listed above are the attributes of a killer salesperson. Needless to say, I did not test high on some of these qualities.

The qualities I tested high on were the following:

• Achiever
• Input
• Learner
• Strategic
• Context

According to my Stryker contact, these are the qualities that make for a good college professor. Oh well, I didn't really want to be a salesperson anyways...

Which brings me to the point of this blog post, which is that I just participated in the:

Centers for Medicare and Medicaid Services
Special Open Door Forum: Developing Outpatient Therapy Payment Alternatives (DOTPA) - Data Collection Update

...and now I have to go "sell" the new DOTPA 17-page physical therapy evaluation form to my friends, staff,and peers. I have to sell this form that may...

1. add to their paperwork burden
2. cannot be used as part of the medical record
3. is not electronic
4. carries no additional reimbursement...

One of the benefits of participating in this voluntary initiative is that clinics and hospitals will receive a 6-month "holiday" from Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) record requests.

Another benefit to participating is that PTs will be among the first to "climb the learning curve" of the new Medicare alternative payment system that is due by May 2013. Physical therapists in Private Practice (PTPP) are among the last to learn these new programs because of time and resource constraints.

Here is the DOTPA slideshow from the August 19th Open Door Forum:



So, are the RAC/MAC holiday and documentation skills the only two features of DOTPA that I've got to sell to my staff? And, are time and administrative capacity the two biggest constraints that PTPP's have in implementing the new Medicare DOTPA 17-page evaluation?

What about selling skills?

How would you "sell" this new program to your staff and peers?

Physical Therapist Payment Options #3

This is the third option discussed in the 2011 Proposed Medicare Physician Fee Schedule published in the Federal Register on June 25th, 2010 and open for public comment until August 24th 2010.  I discussed Option # 1 and Option #2 in previous blog posts.

You can submit your comments directly to Medicare using this link. According to the American Physical Therapy Association (APTA):

If you attach the document, please make sure to include a statement in the text box (e.g. “I am attaching comments in response to the proposed physician fee schedule rule. Thank you for your consideration.”)

Please note that this blog is independent of the APTA and my opinions or blog posts are not in any way associated with the APTA.

Option #3

Twelve new Evaluation and Intervention (E/I) codes that would capture the History, Physical Examination and Medical Riskiness of the physical therapy evaluation.

	Evaluation/Assessment Complexity
Intervention Level	Minimal	Moderate	Significant
None	E/I code #1	E/I code #2	E/I code #3
Minimal	E/I code #4	E/I code #5	E/I code #6
Moderate	E/I code #7	E/I code #8	E/I code #9
Significant	E/I code #10	E/I code #11	E/I code #12

A Significant complex evaluation with Significant interventions would rate a #12 E/I code - the highest payment. Most of the PT diagnoses would be codes #4-9. Also, only physical therapists, physicians or non-physician practioners could bill codes #1-3 and #7-12. Physical therapy assistants could also bill codes #4-6.

Physician Evaluation and Mangement codes are discussed here and using the Interactive Worksheet at First Coast Service Options (Florida Carrier/Intermediary).

Benefits Option #3 represents the closest approximation to physican Evaluation and Management codes that are valued based on...

• History
• Physical Examination
• based on the number of body systems reviewed and
• Medical Decision Making that looks at
• Number of Diagnoses
• Amount of Data reviewed (eg: lab results)
• Risks associated with medical decisions

Holding physical therapists accountable to this standard of decision making can improve our professional autonomy by increasing the demand for data collection.  Basically, the more data you collect the better your reimbursement rate.

Moving away from Fee-for-Service in this way may reward quality over quantity.  Is it possible that the very best physical therapists could see HIGHER reimbursements as they learn the new system and finally get paid better than their "average" peers?

Risks Physicians overutilize testing, mainly diagnostic imaging, in order to reduce professional liability. This reliance on expensive, modern testing drives up healthcare costs and increases the incidence of false-positives, physiologic diagnoses and inappropriate surgeries.

Fortunately, physical therapists do not share this risk. Greater data collection to reduce Medciare Audit risk SHOULD be a goal of any alternative payment system.

Bundled payments, however, are unfamiliar to most small medical providers and may provide inadequate reimbursement for the most complex cases.

Time Frame: 2 to 4 years to implement.

My Call: This is an option I would like to see discussed further - if only for the reason that it suggests that physical therapists can and do make decisions of similar comprehensiveness, complexity and riskiness as physicians.

A Sample Letter from a Private Practice Physical Therapist to Dr. Donald Berwick

...thanks to Melissa Manzione and a well-timed e-mail blast from the American Physical Therapy Association (APTA). Any credit for the value of this post goes to them. The errors are my own.

Dr. Donald Berwick
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–1503–P
P.O. Box 8013
Baltimore, MD 21244–8013.

Re: Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011. (CMS-1503-P)

Dear Dr. Berwick,

I live and work in Florida where about 70% of my patients are on Medicare. I own and work in a private practice in the outpatient setting where our primary interventions are...

• preventing falls in the elderly
• preventing other future adverse events predicted by current findings
• preventing or reducing institutionalization by improving physical strength and function
• and providing an alternative to expensive and risky surgeries.

I am greatly concerned about the recent proposed changes to the Medicare Physician Fee Schedule published in the June 25th Federal Register and due to go into effect January 1, 2011. Specifically, these changes affect outpatient physical therapists by recommending a proposed Multiple Procedure Payment Policy (MPPR) that reduces my reimbursement by 50% for each procedure after the first billed in the same day. Typically, physical therapists bill 4 procedures per day, in my setting.

In my community, Medicare is the fastest insurance payer with the highest profit margin. Medicare allows me to subsidize physical therapy services for many of the working class Americans with commericial insurance that pays at or below cost reimbusement to physical therapists in my setting.

This policy is ill concieved and unfounded based on the following points

MPPR Policy for Therapy Services is Based on Poor Policy Assumptions by CMS

CMS attempts to justify the MPPR policy because the agency believes there is duplication of services since physical therapists typically bill multiple CPT codes on the same date of service. This is incorrect. When the CPT codes therapists use were initially valued through the established and recognized American Medical Association’s (AMA) Resource Based Relative Value System (RBRVS) used by all health care professions, reductions were made to the practice expense component to avoid duplication and represent the multiple procedural nature of physical therapy practice.

In addition, CMS does not account for the multidisciplinary nature of therapy services or the patient’s clinical need for services in this policy

MPPR Policy for Therapy Services will Result in Draconian Cuts that Will Limit Patient Access to Needed Services

MPPR will result in a 12-13% cut to physical therapists under Medicare. This dramatic cut could have serious implications for both therapists and their patients. Practices may be forced to close, facilities may be forced to reduce their therapy workforce, and providers might seek strategies to reduce the number of Medicare beneficiaries they can see due to payment being under cost.

The implications for limited access to care for Medicare beneficiaries if these practice close or do not see these patients is clear and would occur immediately if the MPPR policy is implemented.

MPPR Policy for Therapy Services could have Workforce Implications

Currently, there is a shortage of physical therapists, occupational therapists, and speech language pathologists. Payment policies that cut payments below the cost of providing the services will exacerbate the shortage immediately by staff reductions and practice closings due to inadequate reimbursement and in the future as individuals consider health care professions.

America needs to reduce healthcare cost growth but these policy changes threaten to INCREASE costs if more Americans are institutionalized, suffer falls or increased disablement or received inappropriate surgery as a result of reduced access to physical therapy.

I urge you to reconsider your proposed physical therapy MPPR policy change in the interest of preserving Americans´independence, reducing costs and building a better healthcare system for the future.

Thank you for your consideration,

Sincerely,

Tim Richardson, PT

You can post your letter to Dr. Donald Berwick using the snail mail address in the heading above or you can send your letter electronically to this link:

http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480b182c9

The comment period deadline is August 24th.