Why Physical Therapists Should Make Diagnoses

"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the American Medical Association from John Barnes
CEO, American Physical Therapy Association

12/22/2009

British Physical Therapists Gain Prescribing Rights

"This is a truly historic day..."

The 51,000 British physical therapists (physiotherapists) can now become trained to independently prescribe medications to their patients.

They are the world's first physical therapists to be granted drug prescribing rights within their health care systems without needing a physician to sign the prescription.

"Once suitably trained, physiotherapists in the United Kingdom will be the first in the world to be able to independently prescribe medicines where clinically appropriate,such as painkillers and anti-inflammatories", said Earl Howe, the British Department of Health’s Under Secretary for Quality.

The decision would reduce a layer of bureaucracy and an unnecessary burden on doctors who have, until now, had to counter-sign prescriptions drawn up by physiotherapists who have been "supplementary prescribers" since 2006.

The response from the British medical profession has been overwhelmingly positive.

British physical therapists fought for 10 years to gain independent prescription rights.

I would like to see the same changes take place in the United States of America, however, I am doubtful that the American medical establishment would be as supportive of physical therapists as the British physicians seem to be.

Evidence that increased competition (possibly from physical therapists) drives down prices and increases quality of American healthcare would only be seen as reducing physician income.

Fear of lower physician salaries would draw political opposition from the American Medical Association.

Presumably, Great Britain's "administered price system" (similar to Medicare) is what allows physicians to support physical therapist prescription rights.

What do you think?

Is the Severity-Intensity Model a Roadmap for Fraud and Abuse?

First, I'd like to thank all the hard-working staff and volunteers at the American Physical Therapy Association (APTA) for the effort that went into developing the Severity-Intensity Model, also known as the Alternative Payment System (APS).

Like them, I'd like to see payment reform. But, I want reform that preserves the autonomy of the therapist-patient collaboration rather than depends on centralized oversight of physical therapists by government regulators.

I'm afraid the Severity-Intensity Model may just increase the ability of regulators to audit physical therapists.

Physical therapists are set-up to fail, in every setting, by a documentation framework that was never intended to capture the patient experience of chronically disabled adults.

The Physical Therapy Business Alliance keyed-in on a central flaw in Severity-Intensity in its post at EIM on June 13th, 2012:

"However, the APS in its current form disproportionately emphasizes administrative and regulatory requirements (ie, documentation, compliance, etc.) at the expense of the most critical elements of the clinical encounter, which is incentivizing quality clinical outcomes and patient satisfaction."

We're not alone - this telling indicator of professional consensus is the OVERWHELMINGLY NEGATIVE comments posted at the PTinMotion web site in response to an article on the Severity-Intensity model.

Severity-Intensity Would Increase "Fraudbusting", not fraud
This chart is derived from the Development Draft for APTA Members: An Alternative Payment System for Physical Therapy Services - APTA members have until Friday, June 22nd to comment.

Go to this link and add your two cents.

Recommended Times for Severity-Intensity Patient Visits
	Patient Severity at the time of the Visit
Intensity of Therapist Decision Making	Limited	Moderate	Significant
Limited	30 minutes	30 minutes	30 minutes
Moderate	31 - 45 minutes	31 - 45 minutes	31 - 45 minutes
Significant	45 minutes	45 minutes	45 minutes

The yellow cells are 1-on-1 codes that require individualized interaction between the qualified healthcare professional and the patient.

We all think OUR patients are more difficult to treat than our fellow therapists' patients - this is true in medicine too and is known as Response Bias (seeing what you expect to find). Therefore, using Severity-Intensity we would expect to see a "southeast shift" in coding based on this chart - every patient belongs in the yellow highlighted cells. 

"Code inflation" would occur, based on coding and reimbusement seminars promoted by "Medicare Experts" - here's an example I received yesterday in my e-mail:

"Treatment consists of manual therapy, 97140, to reduce swelling and scar formation followed by passive, active assistive ROM exercise to improve ROM at the knee; 97110, quad sets, SAQ, and SLR to promote the efficiency of the quad contraction and promote quad control at the knee joint, 97112; and finally, I want to put it all together by working on sit to stand transfers emphasizing knee flexion in sitting and equal weight distribution in sit to stand and stand to sit, 97530."

Really?

Is this what we want Doctors of Physical Therapy spending their time on in the 21st century? Writing this blah-blah-blah?

I think your time, and mine, is more valuable than that.

And, technology is increasingly bringing us better documentation alternatives.

Severity-Intensity just adds a layer of complexity on top of the flawed documentation framework that wastes so much time and physical therapist productivity.

What Now?
The Severity-Intensity Model needs to be accepted by the American Medical Association Relative Value Update Committee (AMA RUC) which may then recommend Severity-Intensity to the Centers for Medicare and Medicaid Services (CMS) to be used within its Current Procedure Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) IN PLACE OF the CPT 92505-97799 codes (also a few G-codes and a few others, possibly).

What Do We Use Instead of Severity-Intensity?
The American Academy of Family Physicians (AAFP) has proposed to the Congress a primary care-based Medical Home Model which pays primary care physicians three ways:

• Fee for Service for each individual procedure
• a care management fee that compensates for expertise and time such as management and care coordination that are not direct patient encounters
• Pay for performance based on hitting benchmarked process and outcome measures

I believe the way forward for physical therapists is to move "upmarket", in the words of disruptive innovator Clayton Christensen, and compete directly with primary care physicians for the care of musculoskeletal conditions.

Physician´s Losing Political Clout is an Old Story

The American Medical Association appears to lack the ability to effect political change during this time of crisis and opportunity.  The AMA spent $6.2 million dollars in 2010 but was unable to move forward anything better than a 6-month "doc fix" that will expire on December 1, 2010 - after the mid-term elections.

“For the amount of money that AMA spends, it doesn’t seem to get the bang for their buck,”

...said a senior Republican health staffer who has worked with the group and was quoted at Politico.com .

Physician´s have been losing political clout for almost 40 years. For historical perspective re-read Robert Sandstrom´s The Meaning of Autonomy for Physical Therapy from PTJ 2007.

In his article, Dr. Sandstrom predicts health care reform as inevitable from society´s perspective:

"The position of near absolute control and authority over the health care system by organized medicine bred over time an insularity that ultimately led to a significant reduction in its dominance. As Krause remarked,

“No profession in our sample has flown quite as high in guild power and control as American medicine and few have fallen as fast.”

"The position of unfettered authority results in professional insularity, evidenced by a mission to protect itself, not the public and ultimately to lose support from policy elites.

Although medicine developed and implemented scientific changes that brought improvements in health, sometimes spectacularly, these gains brought significant other social costs.

While medicine maintains an important position of authority in the health care system, the response to this circumstance has been increasing involvement in health care by bureaucracies and weakened professional autonomy."

The AMA has traditionally strong ties to the Republican party but the Association itself is officially non-partisan. The AMA dealt it´s relationship with Republicans a severe blow in late 2009 with it´s early support for Democratic healthcare reform.

"Rep. Michael Burgess (R-Texas), a physician and AMA member, said the AMA’s early support for the Democrats’ health reform legislation tied his hands when he proposed health reform amendments to repeal the Medicare formula and put medical malpractice reforms in place." (Politico.com)

With the AMA on the ropes is it possible that physical therapists can rally to effect political change from the patients´ perspective and best interests?

Can the American Physical Therapy Association pool our efforts and dollars to improve healthcare and gain the trust of the "policy elites" that ultimately make the purchasing decisions in healthcare?

Could the APTA trade political support for the AMA for acquiesence on issues important to physical therapists? (eg: POPTs)

Do physical therapists have an opportunity to gain professional autonomy in this time of crisis?