How Can Physical Therapist Innovators Come Up with Good Ideas?

"Chance favors the connected mind..."

Steven Johnson on Where Good Ideas Come From (Hint: Coffee!)



Thanks to Todd Davenport, PT, DPT, OCS of PacificDPTweet and also on Facebook.

California POPTs Job Loss Differential

In 2005, in Manatee County, Florida a POPTs clinic opened which eventually grew to 17 interventional pain medicine and orthopedic surgeons. I was asked to run the POPTs clinic. I declined.

The clinic grew to employ at least 15 physical therapists in 3 separate locations - in some cases with no full-time physician oversight because they couldn't keep track of who was supposed to be where, when.

In the subsequent two years, 23 independent clinics closed in Manatee-Sarasota county. Each of these clinics employed at least one physical therapist. Many of these clinic employed more than one therapist and 1-3 additional support staff. I closed one of my clinics that employed seven people!

I estimate that with the closing of these 23 independent clinics the job loss differential was probably close to 50 jobs in Manatee-Sarasota counties in that two year period.

Back then, no one complained about jobs. Those were BOOM times in Bradenton. We trailed only Las Vegas in the growth rate of new home construction.

The situation in California now is different. Jobs are scare. If POPTs proliferate they will destroy more independent physical therapy jobs than they create.

My evidence indicates that a 50-to-1 job loss differential is not an unreasonable number.

Comment at the NBC/Los Angeles news website that has run many of the breaking stories on physician ownership/overutilization of physical therapy services in California.

How Physical Therapists Can Add Value to Medicare Accountable Care Organizations

Private practice physical therapists in Florida who understand Medicare Accountable Care Organizations (ACO) are scared about the coming changes in healthcare financing.

But, like many large-scale changes ACOs will bring opportunities for success as well as threats to your current business model.

I'm discussing strengths, weaknesses, opportunities and threats of the ACO model today, August 10th, 2011 at the Florida Health Care Coalition Sixth Annual South Florida Conference Empowering Healthcare/ Engaging Consumers in Ft. Lauderdale, Florida.

Lessons learned here today that physical therapists in private practice can take home:

• Insurance company employees are patients, too. They want better access, process and outcomes of care than they are getting now.
• Wellness and Coaching are proven, albeit expensive, alternative model of chronic care delivery. "Expensive" is relative to the cost of people just taking care of themselves though better diet, exercise and controlling addictive or compulsive behaviors.
  
• Improving behavior is also a proven strategy to lower costs. Whose behavior needs controlling? Patients need better strategies for managing their personal behaviors. Providers need more accountability for our workplace behaviors.
  
• Behavior change skills are fundamentally different from physical therapists' traditional focus on "patient education".
  
• Primary care physicians will be reimbursed for providing wellness care (eg: exercise prescriptions and interventions).
  
• There is a problem with "rouge specialty physicians" driving up costs by performing too many uneccessary procedures, especially in South Florida.
  
• A short-term cost saving strategy will be to increase screening of healthy populations for high-cost, common conditions, like future falls risk in elderly people, comunity-acquired pneumonia and depression in post-surgical patients.
  
  Physical therapists can provide these screenings.
  
• Some insurance companies are experimenting with influencing patient behavior using social media, like Facebook and Twitter.
  

Learn more about Medicare Accountable Care Organizations at the FLorida Physical Therapists in Private Practice (FLPTPP) seminar How Physical Therapists Can Thrive Under Healthcare Reforn in Orlando on August 20-21, 2011.

Sign up now at the FLPTPP website.

You can sign up for the 2-day, 14-CEU seminar here using the web form at the FLPTPP website or you may also register by calling either one of these phone numbers:

1.813.874.2500 (office)

Toll Free: 888-MSK-4331

The course is being held at the Lake Buena Vista Embassy Suites. The Reservation phone number is (407) 239-1144. Ask for the $85 seminar pricing.

Medicare Auditor Describes Threats to Physical Therapists

Come listen to Kathleen Hargreaves, CPA of Kerkering/Barberio in Sarasota speak about Medicare Audits Under the Shared Savings Program (ACOs) at the Florida Physical Therapists in Private Practice Seminar in Orlando, August 20-21, 2011.

Kathleen will describe the threats faced by physical therapist private practices, physician and hospital outpatient clinics, skilled nursing facilities and home health agencies under the new Medicare Shared Savings Program beginning January 1,2012.

The Florida Physical Therapists in Private Practice are a group of eight clinics originally located near Tampa, Florida that incorporated in 2010 as a non-profit physical therapist advocacy group. Our activities this year include the following:

• the August 2011 Medicare ACO Seminar in Orlando
• Signing a group discount purchasing agreement with a major national physical therapy supply company
• Becoming large enough to negotiate with state Workers' Compensation companies for better physical therapy contracts.

You can sign up for the August 2-day, 14-CEU seminar here using the web form at the FLPTPP website or you may also register by calling either one of these phone numbers:

1.813.874.2500 (office)

Toll Free: 888-MSK-4331

The course is being held at the Lake Buena Vista Embassy Suites. The Reservation phone number is (407) 239-1144. Ask for the $85 seminar pricing.

Lower Back Pain, the "The Doctor Effect" and Patient Self-Reported Outcomes

The Doctor Effect is also known as the Placebo Effect.

Except, as pointed out in JournalWatch's Clinical Conversations Podcast #126, Placebos and Medical Meaning, a placebo is an inert substance that has no effect on a patient.

The Placebo Effect was raised by an article in the July 14th, 2011 New England Journal of Medicine Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma. The authors found that patients' self-reported breathing after sham acupucture improved while their Forced Expiratory Volume in 1 second (FEV-1) did not improve. The authors concluded that the self-report measures were therefore unreliable.

Dr. Daniel Moreman, author of Deconstructing the Placebo Effect and Finding the Meaning Response, argues that real, therapeutic effects can be measured in patients who take "inert" substances and that the patient experience (eg: feeling better) may be more important than "instrumental', or objective data, like the FEV-1.

At 11:38 min. in the podcast, Dr. Moreman (an anthropologist) directly speaks to the difficulty of lower back pain, patient self-report outcome measures and physician care.

Physical therapists should think about the Doctor Effect because of evidence that the Doctor Effect, or the process-of-care, may provide at least as large a therapeutic benefit as that provided by pharaceuticals with dangerous or deadly side effects.

Medicare ACO Seminar Features Healthcare Attorney Michael Magidson

Healthcare attorney Michael D. Magidson, Esq of Blalock Walters will present An Overview of Proposed ACO Rules and Regulations for Physical Therapists at the Florida Physical Therapists in Private Practice (FLPTPP) Annual Meeting in Orlando, Florida on Sunday, August 21st, 2011.

Registration details, including continuing education credits for physical therapists and physical therapist assistants, are available at the FLPTPP website.

A Medicare Accountable Care Organization (ACO) is a new type of healthcare devlivery set up under the Medicare Shared Savings Program beginning on Januarary 1st, 2012.

An ACO is a vertically integrated organization run by primary care physicians working for a large hospital or physicians' group. Various downstream providers, including skilled nursing facilities, outpatient physical therapists, physicians' offices and home health agencies, among others, will participate in the care of the patient.

The ACO, and its employees/contractors, will be responsible for 65 quality indicators measuring population health. ACOs who meet all 65 quality standards will be paid a portion of any Medicare cost savings over a certain benchmark.

Michael Magidson, Esq will go into greater detail on ACO regulations at the August 20-21, 2011 seminar in Orlando.

Michael practices in the Business and Health Care Practice groups at Blalock/Walters in Bradenton, Florida. Michael has been advising many of the large mergers happening in the healthcare sector right now. He also counsels clients regarding entity formation and business governance issues.

Physical therapists who want to attend the ACO Seminar can register here.

California POPTs Bill Dies in Senate Committee

Just moments ago, AB 783, (Mary Hayashi D-Hayward) which would override current California state law preventing medical corporations from employing physical therapists and referring patients to their own clinics, died in State Senate Committee.

Five yes votes were needed to move the bill out of Committee, and there were 3 Ayes and 2 Nos and 4 Senators didn't vote.

Aye votes were Vargas, Correa and Wyland.

No votes were Price (Chair) and Walters.

The Chair declared the bill failed to move out of committee and allowed for reconsideration at a later date.

It is unclear when the bill will be reheard, but we will keep you posted.

Thanks to all of you that sent emails to your state legislators.

Thanks to those members of the California chapter who fought this fight for all of us.

Diet and Nutrition for Physical Therapists

International Networks Archive / Map of the Month

"Princeton offers a look at two different infographics describing the place of McDonald’s and Starbucks in public health implications that are related to the foods they show.

Sometimes we forget how much sugar Starbucks coffee has, and the lack of nutritional value in McDonald’s food.

An eye-opening infographic that provides an interesting look at the way we eat — and how it is being exported around the world."

Click the graphic to enlarge it in your browser.

Thanks to Allison Sharp at the Health Hawk.com

Comparative Effectiveness Research Under Attack

A cornerstone of the healthcare overhaul and a vital tool outlining the value of physical therapist practice is under attack.

Comparative Effectiveness Research (CER) will cost the United States $4 trillion in economic activity, according to a new report from the Center for Medicine in the Public Interest (CMPI).

The report argues that investment in new drugs and medical devices would suffer:

"Investments in medical research provide among the most productive uses of capital in the economy.
Americans will suffer economically and physically if the government forces CER on the U.S. healthcare system", said Robert Goldberg, vice president of CMPI and a study author.

Investments in one of the most lucrative medical devices, pedicle rods and screws, made by publicly-traded firms like Zimmer, DePuy and Stryker are a major cost driver in healthcare cost inflation.

These firms have driven the rate of dangerous, complex spinal fusion surgery up 20 times since 2002. These patients have three times the risk of dangerous complications and twice the risk of a rehospitalization.

Oh, and by the way, the new surgeries sponsored by the medical device "investors" cost at least $80,888, compared to $23,724 for regular back surgery.

Physical therapists treatments for similar conditions don't carry these hefty price tags and dangerous risk profiles.

A survey of 111 major stakeholders in drug and device manufacturers believe that, in the long run, CER will improve healthcare outcomes and "expressed tempered optimism" about its implementation by the government.

Physical Therapists Can Improve Patient Safety in Hospitals

One of the "failure modes" in preventing hospital-acquired venous thromboembolism (VTE) - a blood clot - is that risk assessment is not routine or standardized.

Physical therapists who treat post-surgical patients can provide screening to diagnose this problem in high-risk patients. Screening rules, such as the Wells' Criteria can aid the physical therapist in diagnosing a blood clot.

But, one physical therapist cannot create a culture of safety.

To create a culture of safety in preventing hospital-acquired infections the Agency for Healthcare Research and Quality has sponsored a Comprehensive Unit-based Safety Program (CUSP). The CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms.

The program features: evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership, and tools to improve teamwork among doctors, nurses, and other members of the health care team.

The CUSP uses a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders.

Step 1 Staff are educated on the science of safety.

Step 2 Staff complete an assessment of patient safety culture. Safety is everyones' responsibility - we as physical therapists cannot continue to defer our responsibility to physicians on the "sharp end" of healthcare.

Step 3 A senior hospital executive partners with the unit to improve communications and educate leadership. Staff (MDs, nurses, PTs, etc) need to know we have support from the top.

Step 4 Staff learn from unit defects. These defects get reported by staff members unafraid of personal attacks.

Transparency, like in the airline industry, celebrates the reporting of medical errors as the opportunity to learn and improve. Instead, in healthcare, we've had a habit of "naming, blaming and shaming" people who make mistakes. A broken tort system of punitive legal redress is the product of these habits.

Step 5 Staff use tools, including checklists and electronic decision support, to improve teamwork, communication, and other systems of work.

Clinical decision support tools, with reminder pop-ups, prompts and suggestions can help physical therapists provide guideline-adherent care.

The most common preventable cause of hospital death is VTE.

"Over 1 year, a 300-bed hospital that lacks a systematic approach to VTE prevention can expect roughly 150 cases of hospital-acquired VTE.
Approximately 50 to 75 of those cases will be potentially preventable because of missed opportunities to provide appropriate prophylaxis.
Approximately five of those patients will die from potentially preventable PE."

Highly focused initiatives using these five principles have achieved success in reducing preventable infections, such as central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections, and ventilator-associated pneumonia, in intensive care units (ICUs) and other hospital units.

Healthcare leaders can address the growing rate of blood clots by attacking this problem with teams of providers implementing a standardized approach.

Support Texas Physical Therapists!

Texas direct access bill, HB 637, needs your help!

This screenshot shows that the Texas Direct Access bill has been stuck in committee since April 20th and the session is winding down.

The expected vote is a dead heat, 3-3.

The session began on January 6th and lasts for 140 days. That leaves only about three more weeks for physical therapists to gain direct access in Texas! The Texas legislature meets every odd-numbered year so this will be our last chance until 2013.

Go here - the Texas Direct Access website - where you can call a Texas legislator, donate money or sign a petition.

Calorie Counting and Metabolic Feedback for Physical Therapists' Patients

The Aipermotion Active Body Control device:

Physical therapists can use Aipermon's new Active Body Control device to help their patients adhere to their diet using instant feedback of calories burned and calories taken in.

The device is part calorie calculator and part pedometer with an internet connection that sends your results to your doctor.

Poor Nancy has not had breakfast yet but she's a good trooper and she demonstrates the Aipermotion for me at the American Telemedicine Association (ATA) meeting in Tampa using her own metabolic data.



Thanks Nancy! Now, go get some breakfast!

FPTA Legislative Advocacy Meeting

I rode the plane up to Tallahassee with John Walz, PT to the FPTA Legislative Advocacy Meeting on March 14-15, 2011. I had been up the year before but John was new to this process. He worked in outpatient rehab but was totally uninvolved in politics. While I’ve become a bit of a political junkie John was the least political person I know – he liked everybody and everybody liked him.

What made John a candidate for State Advocacy training was his community activism – he was a Boy Scout leader, he held leadership positions in his church and he owned three outpatient clinics in Manatee County, Florida. John had political connections where they counted the most – at home.

One of our conversations on the plane brought to light that he bought insurance policies from our new Republican Representative in the State House. This contact may be valuable in the future as physical therapists seek to present our position to legislators in Tallahassee.

Some of the issues John and I learned this year in Tallahassee were among the following:

• How to approach your legislator by Jack Latvala (R) St. Petersburg – real down-to-earth talk about what legislators need to hear from constituents.
• The CEO of the FPTA discussed FS 486 and the Florida Administrative Code 64B17.
• Tim Richardson, PT discussed fundraising and how to set-up, organize and ensure attendance for your fundraiser.
• Eric Chaconas, DPT discussed the Florida Key Contacts Network.
• Nancy Stewart, JD, our attorney and lobbyist in Tallahassee discussed some current issues:
• PIP fraud and attorney’s fees
• No PIP legislation this year
• Clinic licensure
• Pill mills
• Gene Adams, our attorney and lobbyist in Tallahassee discussed other current issues:
• Consensus prediction for the 2012 session
• No change with PIP legislation
• No need for additional clinic licensure

The following day, the assembled Advocacy members went to see our representatives in their state offices. John met his Representative and we arranged to get together back home in Bradenton to do a barbeque after the 2011 session finishes on May 6th.

On the plane ride home, John and I received a quick, 15-minute tutorial on the legislative process from the outgoing President of the Florida Association of Anesthesiologists.

Anesthesiologists have lobbied seven years under this man’s watch to restrict “Pill Mills” in Florida. 2011 is the first year they are expecting significant legislation to protect their profession. Change happens slowly in Tallahassee.

What you can do to help physical therapy is to identify people in your community like John – your friends, your coworkers or yourself. Don’t worry about political interest or experience. Is this person involved and interested in their community? That’s who physical therapists need to represent our interests in Tallahassee. They’re the ones we need as Key Contacts around the state when important legislative issues come up.

If you or someone you know fits the description like John fits can you recommend them for the sponsored 2012 State Advocacy Training next year in Tallahassee?

If you do, contact Eric Chaconas, DPT at echaconas@usa.edu and let him know you are interested in becoming a Key Contact.  If you're interested in attending State Advocacy mark your schedule for February 2012 and apply for a scholarship.

Creeping Corporate Physical Therapy in California

Business interests in California are prevailing over consumer protection.

New legislation has now passed in two committees to add physical therapists to the list of professionals allowed to be employed by non-professionals.

As of April 5th, AB 783 (Hayashi Bill) has now passed, unanimously in both cases in the Assembly of Business and Professions and the Assembly of Business, Professions and Consumer protection.

The new legislation will circumvent the intention of California's Moscone-Knox Professional Corporations Law that passed in 2003, which is to protect the actions of professional from being corrupted by corporate business interests, primarily motivated by profit.

The main corporate business interest employing physical therapists is physicians, podiatrists and chiropractors.

Until now, California has been viewed as having one of the stronger professional corporations laws in the country.

The Hayashi Bill reads, in part:

"Existing law regulating professional corporations provides that certain healing arts practitioners may be shareholders, officers, directors, or professional employees of a medical corporation, podiatric medical corporation, or a chiropractic corporation, subject to certain limitations.

This bill would add licensed physical therapists and licensed occupational therapists to the list of healing arts practitioners who may be shareholders, officers, directors, or professional employees of those corporations."

There is heated debate on both sides of this issue: physicians affirm their right to practice medicine, including physical therapy, within their professional license.

Physical therapists oppose AB 783 mainly as an issue of costs - physicans who own their own physical therapy clinics drive up service volume by 30% and reimbursement by 40%.

Doctor Happy and the Silent Treatment

A new study highlights an old problem in medicine that leads to patient harm.

A new study from VitalSmarts, the American Association of Critical-Care Nurses and the Association of Peri-Operative Registered Nurses (AORN) called The Silent Treatment describes several categories of "undiscussables" in medicine:

• Dangerous shortcuts
• Incompetence
• Disrespect

As I shared here, even physical therapists are subject to events that lead to the silent treatment.

Teams of healthcare workers in the future will need to learn positive ways of influencing each others' behavior but not bullying, yelling or disrespectful behavior.

The silent treatment happens anytime communications between physicians and other workers break down. "Other workers" can include nurses, physicians' assistants, physical therapists or even clerical people. My experience with a particular orthopedic surgeon falls under the "disrespect" catagory.



Acoording to the American Association of Critical-Care Nurses (AACN):

"More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16 percent confronted their disrespectful colleague."

My story goes like this:

The orthopedic surgeon called me two weeks after the patient's operation. I had seen the patient once, or maybe twice, at that point, for rehabilitation of his full-thickness rotator cuff repair. The patient was on the standard six week protective protocol, passive range-of-motion only and pendulum exercises at home.

The incision was still swollen and tender. Motion, even passive motion, was quite painful. The patient was still having trouble sleeping at night. Therapy consisted of maybe 20 minutes of passive mobility in six directions, the aforementioned pendulum exercises followed by electrical stimulation and ice.

I got called in the middle of the work day by the physician who we'll call Dr. Happy. When I picked up the phone, Dr. Happy practically yelled,

"Tim! What the hell are you doing letting my patient get stiff?"

I knew better than to argue. "He's still very sore, Dr. Happy" I said.

Dr. Happy continued, "You'd better improve internal rotation! He can't get his arm up his back! He's going to get a frozen shoulder!"

"We won't let that happen, Dr. Happy!" I said.

That might have been enough - a sharply worded reminder to improve joint motion - except for what came next.

"You like my referrals - don't you?". It wasn't a question.

"Yes sir!" I said, dreading what I knew was to follow.

"You'd better not let him freeze up or I won't send any more referrals to your clinic!" growled Dr. Happy

The question is not whether Dr. Happy was justified in chewing my butt, or whether my patient actually was stiffening up (he wasn't).

The questionable behavior is Dr. Happy's abusive, disrespectful and bullying attitude that, unfortunately, was not seen as abnormal in the culture of American medicine.

Nowadays, hospital safety is changing as a result of checklists, computerized decision support tools and new surgical protocols. But, these new tools won't create a safe culture as long as people disrespect each other to enforce a culture of silence.

Tools don't create safety, people create safety.

The culture of silence is beginning to change.

Quality Measures Physical Therapists can Use to Prepare for Meaningful Use

Physical therapists can begin using these quality indicators in their clinics, if you're not already:

Treatment of depression: ask "Are you depressed or have you felt sad or blue during the last 30 days".

Smoking cessation advice among smokers: I read this this on a pack of Camels... "Quitting smoking now can greatly reduce your risk of death from cancer, heart attack or stroke".

I usually ask the patient if any other medical provider has asked them to give up smoking. Over 80% say that their doctor has asked them - but, that means that up to 20% have not been asked to quit!

Diet advice in high-risk adults: I'm 175lbs, 42 years old and I still look good in a Speedo so I punt this one, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in high-risk adults: "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I actually try not to use the word exercise until the patient has used that word, with me, at least once.

Diet advice in adolescents: same as with the adults, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in adolescents: same as with the adults, "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I'll usually mention sports, or for the college bound, I'll mention the rigors of studying and computer use.

Blood pressure measurements: This is, by now I think, routine in most physical therapists offices and clinics but I could be wrong.

One point of discussion we haven't settled... Do you take blood pressure on EVERYBODY or just those you consider "high risk". Good resource allocation principles would indicate that your therapists' time is valuable and routine screening on everyone is wasteful.

The Impact of Quality

These measures come from the National Ambulatory Medical Care Survey (NAMCS) that has been collected on a sample of patient visits to non-federal employed office-based physicians who are primarily engaged in direct patient care since 1973.

A recent impact study in the Archives of Internal Medicine on the effectiveness of Electronic Medical Records (EMR) with Clinical Decision Support(CDS) prompting the use of these quality indicators in 255,402 physicians' practices found that only two of twenty possible indicators were improved with the use of the EMR/CDS.

This new study casts doubt on the wisdom of the $27 billion dollar HITECH investement for EMR showing meaningful use capabilities.

Many recent studies of electronic clinical decision support have found improvements in the process of care, like inappropriate antibiotic prescriptions, with the use of electronic aids at the clinic or the hospital level.

This study looked at visit data aggregated nationally to see if the same local trends persisted but they didn't.

Can Physical Therapists Move Forward?

Absolutely. The first step would be to adopt these quality measures - there is no controversy about quitting smoking. Its good for your patient and its within your skill set.

Don't rush out and buy yourself an electronic EMR/CDS just yet - 80% of physical therapists are still on paper.

Fax the paper to your referral sources and let them scan it into their new, government sponsored EMR.

I think the future will reward those of us who focus on quality.

200 Years of Health and Wealth

How do health and wealth interact? This video provides an entertaining look at worldwide healthcare systems over the last 200 years. Most of the past health gains have been made conquering infectious diseases and acute problems, such as heart attacks. Where will the gains in the future come from? Beating chronic conditions. Physical therapists are in position to provide better healthcare for chronic conditions into the 21st century:

(4 minute video)


Leave a comment - what do you think about this video?