The ‘S’ Word in Health Care

Americans greatest fear in today’s debate on health care may be the spectre of the ‘S’ word – socialized medicine.

Socialized medicine is ‘code’ for the government takeover of healthcare (already 50% ‘taken over’ by Medicare).

Socialized medicine is a poorly-defined, alarmist and pejorative label that describes Americans’ fear that individual medical decisions made between doctor and patient will be replaced with decisions made in some far-off place, like Washington DC or, possibly, Bangalore, India.

I sure don’t want this possible future scenario for my doctor to be forced to do this to treat me:

1. pick up the phone to a call center in Bangalore to get approval for my flu shot
2. wait on hold for 15 minutes
3. describe my symptoms to ‘Steve’ from Bangalore
4. wait on hold for 15 more minutes
5. then get the rejection with a recommendation to try the generic, cheaper alternative.

Rationing Health Care

The other, common usage of the ‘S’ word is in context with rationing. Rationing is another politically charged word often used to describe denial of payment based on price. Rationing is not a question of ‘if’, but ‘how’ as this article from the New York time suggests.

Similarly, and seriously, decisions about needed surgeries, diagnostic testing, preventative testing and treatment options are best made locally between the doctor and the patient.

The Moral Imperative

No worthwhile physical therapist needs to be told the moral imperative in healthcare: Do what is best for the patient. The Oath of Maimonides said to originate from a 12th century Jewish physician-philosopher is perhaps most appropriate:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.
Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

The Financial/Business Imperative

Health care delivery in America often contrasts with the moral imperative in health care. Medical businesses exist to do the following:

• make money
• provide professional autonomy
• ensure high standards of care
• allow physical therapists to practice in specialized settings

– however, the first imperative is money, without which further imperatives are irrelevant.

The American health care market, through fee-for-service, creates an incentive for physical therapists to provide higher volumes of care than is necessary.

Medicare fraud and abuse prevention efforts, in general, and the PT Cap Exceptions Process, specifically, encourage PT firms and private practices to limit necessary services to patients who need them.

The 'Black Hats'

In my town of 400,000 we have a 13-doctor practice that, in purely rational self-interest, automatically discharges patients when they hit the ‘PT cap’.

They've abdicated their moral imperative in favor of their financial/business imperative.

I use a POPTs example because, as a private practice physical therapist (PTPP), it’s fun to pick on POPTs. Based on purely rational self-interest, however, another PTPP might choose to make the same business decision and discharge patients who hit the arbitrary cap based on perceived audit risk.

Are they bad people? No. They work in a bad system.

POPT's are not evil, they’re not bad people and they’re not even bad medicine – some even do a pretty good job of post-surgical PT if anecdotal stories are to be trusted. Some of my friends work for POPTs.

But any policy that unnecessarily drives up costs and drives a financial divide between decisions made by the PT and the patient is bad health care policy. The same would be true for policies that distort with dollars decisions between physicians and patients.

How can physical therapists reconcile the two imperatives in private practice PT in America? Surely pushing decisions to far-off decision-makers is less efficient and, presumably, less effective than one-on-one decisions between doctor and patient.

Right?

Older physical therapy patients are worried

Every day I answer questions from older Americans about their physical therapy.

"Will I run out of Medicare physical therapy benefits?"

"What will happen to me - will I have to go into a nursing home?"

Medicare provides physical therapy treatment up to $1,810 in billed charges for the purpose of preventing a loss of independance in older Americans.

Americans living at home, cared for by their loved ones, consume fewer healthcare dollars than Americans living in institutions.

Medicare pays for much of the institutional care in the United States.

Sarah

Today, I treated Sarah, an 86-year old lady with arthritis.  

Sarah is legally blind and cannot walk far because of pain in her back and legs due to a condition called spinal stenosis.

Sarah's husband died a few years ago and now she is alone. 

Sarah can clean her home and care for herself with minor accomodations - she rides the handy bus to church, groceries and physical therapy.  

She doesn't go out much but she lives in a trailer park where neighbors are close by.

But, Sarah is not far from needing more help.

She has been in physical therapy for her spinal stenosis for a month now and we have gotten her back to walking and single-stair climbing (we live in Florida). 

Sarah is much more comfortablenow moving around and doing light lifting.

Friday, November 7th is Sarah's projected discharge date and she is worried that physical therapy will not continue.

She is afraid that she will decline without therapy and require more help to live alone.

Soon, she believes, she will need to move out of her trailer and into a nursing home.

Sarah believes physical therapy can help prevent this decline.

So do I.

Medicare depends on me to prevent Sarah from losing her independance and going to live in a nursing home.  But, for that, I have to make decisions that expose me to the threat of a Medicare audit if it is determined that I gave Sarah 'too much' physical therapy.

What do I do?

I must show that I can help Sarah, that Sarah needs my help and that only a physical therapist, such as I, could help Sarah.

For that I need help.  I need two tools.  Both are free tools.

The first tool is the OPTIMAL.

I use the OPTIMAL to show that Sarah needs physical therapy.

The OPTIMAL also shows that Sarah can now walk further and move around better than she did one month ago.  It shows she makes progress in physcal therapy.

But, I also need one more tool.  I need to append a '-kx modifier' to my physical therapy charges that I send to Medicare.  

I want to show any Medicare auditor that my decision to append that modifier is based on results, not just a one-time event or measurement.

So, I graph my OPTIMAL scores.

Here is the graph template.

What happens to Sarah?

Friday I take my follow-up measurements.  

Sarah's need and progress is evident.

My skill and decisions are well-documented with the graph template.

This time, I think she will qualify for the extra month of physical therapy.

Dororthy got kicked out of Physical Therapy today

Dorothy got kicked out of physical therapy today.

Dorothy is one of my patients.

She is almost 80-years old, still lives at home with her husband and tries to walk every day.

She lives year-round here in Florida in the same town she grew up in.

Dorothy has a condition, called degenerative spinal stenosis, that causes her back to hurt when she walks more than one city block.

Dorothy has been to my physical therapy clinic for treatment of her stenosis three times in 2008: January, May and now in October.

Each time she has come to see me we have been able to help her walk better and maintain her independence.

Only now she has used up her Medicare physical therapy benefit.

I say she got 'kicked out' because that's how I felt when I told Dorothy that Medicare would likely no longer pay for her care.

Sure, Dorothy had the option to pay cash but, at $100 per treatment session, that is not much of an option.

I felt like crap when I walked her to the door and gave her a hug and said goodbye.

She was much kinder to me than I was to myself.

Dorothy said she understood the situation and that she would do her exercises at home.

What will happen to Dorothy?

The reality is that that Dorothy will begin a functional decline without skilled physical therapy.

How do I know?

I measured it.

In January, May and October I took functional measurements of Dorothy with a Medicare-recommended tool called the OPTIMAL scale.

Each time Dorothy came to therapy we re-measured her performance on the scale. Each session of physical therapy showed improved performance on the OPTIMAL.

Each time Dorothy stopped physical therapy her performance declined. The treatment effect was not persistent.

Dorothy's muscles around her spine were too weak to support her aged bones and discs.

Dorothy stopped walking because walking hurt.

She couldn't clean her house because vacuuming hurt her back and her husband had to do it.

She had to depend on her husband more and more and soon his back began to hurt.

At one point, I had both Dorothy and her husband in therapy.

The husband soon got better but Dorothy noticed that she was unable to push herself at home sufficiently to exercise her muscles. Also, she didn't have the specialized equipment, like spinal traction and exercise equipment, that we had in therapy.

Because of her age and her aptitude she was not safe working out in a self-pay gym setting.

Even a personal trainer was not a safe option for Dorothy.

What will I do?

If Dorothy calls me again in 2008, asking for help, I will see her for an evaluation.

Physical therapy evaluations are not subject to the cap.

Technically, you should not even have to append the -kx modifier to a 97001 CPT code for a patient over the cap since you need to evaluate them first to see if they qualify for the automatic exceptions to the cap.

In your evaluation you should measure impairments in body structure and function as well as activity limitations.

Link the impairments to activity limitations with your physical therapy diagnosis.

I measure activity limitations with the OPTIMAL scale.

Dorothy's OPTIMAL scale was graphed for 2008.

Here is what the graph looked like and how it provided the justification for going over her annual $1,810 per beneficiary, 'Uniform Dollar Limitation' (cap).



If you need to learn about 'justification statements' or 'the exceptions process' or even 'medical necessity for physical therapy' you can get free information at Bulletproof Physical Therapy Charts.

Give your patients all the physical therapy they need.

Unless they're ready, don't kick them out.

Arnie Falls Down a Lot and He Needs Physical Therapy

Arnie falls down a lot and he needs physical therapy.

Arnie is a 74 year old bookkeeper, living with his wife Betty in a trailer in Florida.

He lives on a fixed income - social security and some retirement income. He gets his health care from Medicare.

He has no pension since he lost his good job in the recession of 1990 and he has had to work odd jobs for the past 15 years.

Now, Arnie is weak in the legs and his balance is bad.

He fell down six times in two weeks in August and asked his doctor for a referral to physical therapy.

Physical therapy has a falls prevention program of strengthening, balance, flexibility and falls awareness training that has been shown to help seniors prevent falls and increase mobility.

But then, Arnie fell on a rain-slick driveway at night and landed on his shoulder - he ended up tearing his rotator cuff.

Arnie had used up 12 of his physical therapy visits and Medicare only allowed him about four more visits.

In America today, there are many people like Arnie - denied their Medicare physical therapy even though they clearly need help.

Today is October 25th, 2008 and every Medicare beneficiary in America has about $1,810 in physical therapy benefits for the entire year.

Unfortunately, by now many have used some or all of their benefits and could face a difficult and painful recovery if Medicare wont pay for extra physical therapy.

Fortunately, there is a solution.

Many therapists (and doctors) are unaware (or afraid) to use this solution.

The Exceptions Process

The $1,810 physical therapy Medicare cap has an exceptions process based on need and expected patient progress.

If I can show that Arnie needs extra therapy (he does) and that I can expect to get his shoulder better and prevent future falls, then he can have his extra therapy.

Therein lies the rub.

How to make the case for Arnie?

The need is easy.

Arnie is a train wreck, poor guy.

I measure his strength, flexibility and range-of-motion, as well as activity limitations using standardized test scores.

Future expected benefit is the hard part.

Many physical therapists don't know how to show expected future benefit from physical therapy.

You need to show a positive trend in your standardized test scores.

You should then graph your trend line to provide an easy visual reference for anybody who questions your decision or audits your chart.

Create a graph template that you can fill in with one, two or three months worth of test scores.

When you connect the dots the trend line should be going up - this indicates progress.

Download this free template at www.BulletproofPT.com.



Remember to modify the template to fit the needs of your physical therapy facility.

Orthopedic surgeon limits patient access to physical therapy

It's October 11th and Medicare patients are losing access to their physical therapy services.

Yesterday, I saw one of my 'snowbirds'. She is 79 years old and she spends the summer in Maine and the winter in Florida (I live in Florida).

She came in to see me in January and had rehab on her rotator cuff. Now, she is back because she fell on the golf course and injured her knee.

Her orthopedic surgeon saw her after the fall gave her a cortisone shot and four visits to therapy.

Four visits?

The surgeon didn't give her more therapy in case she needed surgery.

He explained didn't want to 'use up' her therapy by hitting the Medicare cap. He felt she would need more therapy after surgery.

The cap is a spending limit that Medicare applies to every beneficiary. This year the cap limits the beneficiary to $1,810 in billed physical therapy.

Typical physical therapy billed charges use up the cap in 16-20 visits.

Patients are coming to me now who have used up their benefit in July, or May or whenever.

What the surgeon didn't know (or didn't tell) was that the physical therapist can apply for an exception in special circumstances.

The exception is based on three simple things:

• Patient need
• Patient progress
• Physical therapist decision-making

In other words, this lady had just fallen down, she was at increased risk for future falls and she was not getting her physical therapy based on her surgeons' interpretation of the Exceptions Process to the Medicare Cap.

With all due respect, most surgeons should just stick to surgery.

Physical therapists in outpatient, non-hospital clinics can examine their patients, case-by-case, to see if the patient has characteristics that would qualify for the exception.

The fact that this surgeon was the owner of one of the largest non-hospital physical therapy clinics in the state of Florida and a direct competitor of mine may have had something to do with his 'interpretation'.

I don't know.