What has the American Physical Therapy Association done for you lately?

Patient stories...

Physical therapists hear these stories every day but the APTA is helping to put patient stories where they will do some good - in front of legislators who can determine your Medicare reimbursement.

The APTA coordinated a recent practice visit with the office of Federal legislator Vern Buchanan (R-Bradenton) on Tuesday, August 6th at a private physical therapy clinic in Bradenton, Florida. The following stories are a good example of what the legislator heard that day...

The 82-year old female patient gave a lucid, moving story about how her physical therapist had 'saved her life' by helping her remain living at home after a fall and a hip fracture. She mentioned she was already at the 'hard cap' of $3,700 in 2013 and didn't know how she could continue to pay for the services of her therapist even at the reduced frequency of one time per week.

The male patient, a retired veterinarian, told a very funny story of dislocating his shoulder by, believe it or not, walking his big dog. He was offered imaging and surgery by an orthopedic surgeon who owns therapy services. The patient said he wanted to think about these two options and, in the meantime, could he get a referral to physical therapy? That was three months ago and he now has full passive ROM. He is in no pain. He is also at the 'hard cap' but he credits his physical therapist with preventing what was, in his opinion, an unnecessary surgery.

Therapy Cap is top-of-mind for physical therapists because we deal with it every day but most legislators and their staff have many other responsibilities. Patient stories help make the recent Therapy Cap legislation REAL for members of the Congress by putting a human face on the problem.

The Medicare Access to Rehabilitation Services Act (HR 713) was recently introduced in the House of Representatives by Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA).  HR 713 would permanently repeal the $1,900 therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services.

We asked Congressman Buchanan to support HR 713 by attaching it to another bill that is gathering momentum in Washington DC.   The Medicare Physician Payment Innovation Act (HR 574), introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV) provides the following:

• repeal and replace the flawed Sustainable Growth Rate (SGR) formula.
• a clearly defined path to permanent Medicare payment reform.
• it includes a multi-year period of payment stability for Medicare providers.
• a stipulated annual payment rate increase of 0.5% to the Physician Fee Schedule.
• CMS will test and evaluate several alternative payment systems including the Alternative Payment System for therapy proposed by the American Physical Therapy Association. 

For the first time in many years, there is bipartisan support for repealing and replacing the SGR and fixing Medicare reimbursement for physical therapists via HR 574.  There is also a chance to fix the Therapy Cap by attaching HR 713.

To improve our chances you need to contact your legislators with your patient stories.   

Picking Physical Therapists' Pockets...

Physical therapists in private practice (and other settings) should understand where most our dollars come from.

In Florida, with our large elderly population, about half of my practice income is Medicare reimbursement.

That reimbursement is getting smaller - not due to budget cuts - but due to the activities of specialist physicians.

We haven't had an actual Medicare reimbursement cut since 2002.

Despite the media hoopla about the effect of the (Un)Sustainable Growth Rate on the Medicare Physicians' Fee Schedule, the Congress of the United States has failed to implement budget balancing reforms on Medicare reimbursement.

Year	Projected Update to the SGR	Actual Update to the SGR
2002	-4.8%	-4.8
2003	-4.4%	1.4%
2004	-4.5%	1.5%
2005	-3.3%	1.5%
2006	-4.4%	0.2%
2007	-5.0%	0%
2008	-10.1%	0.5%
2009	-10.6%	1.1%
2010	-21.3%	0%
2011	-27.4%	0%

So why has my relative income continued to decline?

The Relative value Update Committee (RUC) of the American Medical Association each year recommends changes to Medicare reimbursements that reward specialty physicians yet penalize general medicine and preventative services.

Specialists are picking physical therapists' pocket and most physical therapists don't even know it!

The media and our own professional political advocacy would have us focus most of our attention on the SGR. However, the RUC is, according to Dr. Brian Klepper...

"...the greatest obstacle to turning around our healthcare system and our economy."

Dr. Klepper details the scope and scale of this problem in his August 2012 blogpost The Most Powerful Health Care Group You’ve Never Heard Of

Dr. Klepper has also formed the advocacy group called Replace the RUC to generate public awareness of this shadowy politcal group.

Who thinks physical therapy codes are under-valued relative to certain other medical procedures?

Which codes? Which procedures?

Thanks for commenting.

Outpatient physical therapists under scrutiny by Office of the Inspector General

The OIG 2009 Work Plan has several areas that address outpatient physical therapists directly.

• Outpatient Physical Therapy Services Provided by Independent Therapists

"We will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements.
(OAS; W-00-09-35220; various reviews; expected issue date: FY 2009; new start)"

• Physicians’ Medicare Services Performed by Nonphysicians

"We will review services physicians bill to Medicare but do not perform personally. Such services, called “incident to,” are typically performed by nonphysician staff members in physicians’ offices. The Social Security Act, § 18610(s)(2)(A), provides for Medicare coverage of services and supplies performed “incident to” the professional services of a physician. However, these services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. We will
FY 2009 OIG Work Plan 15 Centers for Medicare and Medicaid Services
examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care.
(OEI; 09-06-00430; expected issue date: FY 2009; work in progress)"

Outpatient physical therapists with high, unexplained utilization rates will have to show good documentation for their charges.

Physician-owned physical therapists will also have to demonstrate the following:

• Medical necessity for physical therapy (treatable findings)
• Expectation of significant improvement in a reasonable time frame (progress)
• Skilled physical therapy (PT decisions or PTA clinical judgment)

For a step-by-step program that a PT manager can implement without becoming a 'Medicare expert' go to BulletproofPT.com to protect yourself and to sleep well.

Predictive physical therapy: can questionnaires aide prognosis?

There is a new age of accountability (financial, regulatory and otherwise) in physical therapy.

Some examples...

Physical therapists are being asked to work and get paid based on their productivity rather than a fixed salary.

Medicare requires physical therapists to 'diagnose' their patients using objective, public-domain tools, like the OPTIMAL scale.

Now, physical therapists can predict whether patients will adhere to physical therapy after spine surgery. The test is called the Patient Activation Measure (PAM) questionnaire.

"Essentially, the test places patients on a continuum of activation ranging from those who don't see an active role on their part as necessary to those who are highly motivated to take an active role in their own health care." said lead author Richard L. Skolasky, Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

My professor in physical therapy school once told me that questionnaire data was 'soft' and that we needed 'real numbers' for good decision-making in physical therapy. In 1992, my professor called questionnaire data 'subjective' data.

Well, that was 1992 and this is 2008.

In 2008 and beyond, more of our physical therapy data will come from questionnaires. The good news is this... questionnaire data is good data.

The test that is destined to replace the OPTIMAL scale is the Activity Measure for Post Acute Care (AM-PAC). The AM-PAC produces good data.

Data is going to be necessary for physical therapists to demonstrate value to payers.

In 2006, the single largest purchaser of health care in the world, US Medicare, spent $3.06 billion on physical therapy.

Questionnaires can give us good data.

Good data can improve physical therapy accountability, diagnosis and prognosis.

Physical therapists and doctors: Get ready to hand over more documentation

Much in the news lately is the Office of the Inspector General Investigation of the Comprehensive Error Rate Testing Program.

As I blogged on Sunday, August 24, 2008 you-know-what will run downhill on this one.

Here is the OIG report for your reading.

In summary the report states the following:

"We recommend that CMS:

• require the CERT contractor to review all available supplier documentation;
• establish a written policy to address the appropriate use of clinical inference;
• require the CERT contractor to review all medical records (including, but not limited to, physicians’ records) necessary to determine compliance with applicable requirements on medical necessity;
• document oral guidance that conflicts with written policies, such as guidance on the need for proof-of-delivery documentation in making medical review determinations;
• instruct its Medicare contractors to provide additional training to physicians that focuses on improving their medical record documentation to support ordered DME items; and
• require the CERT contractor to contact the beneficiaries named on high-risk claims, such as claims for power mobility devices, to help determine whether the beneficiaries received these items and the items were medically necessary."

I've highlighted in red the requirement that I believe will lead to tougher audit standards on physical therapists and physicians - already overburdened with declining reimbursements and rising costs.

Medicare Auditors Get Spanked

Health care providers can expect this one to flow downhill like you-know-what.

All across the blogosphere, reports of the draft report from the HHS Office of the Inspector General are streaming in...

Miami Herald Aug. 21

ProPublica Aug. 22

Tampa Tribune Aug. 21

Judicial Watch Aug. 22

Looking for the Outliers Aug. 23

Who Will Audit the Auditors? Aug. 22

Medicare claims $700 million in fraudulent savings to the federal health care program for elderly and disabled persons.

The New York Times (Aug. 20) claims the amount should be over 4 times that amount - almost $3.2 billion - that may have been swindled by unscrupulous medical device providers like wheelchairs and motorized carts.

Medicare failed to follow its own internal accounting controls in estimating the amount of fraud.

Congress and Senator Charles Grassley
are mad.

"I want to know what happened, who's responsible, who will be held accountable and what the [Human Services] secretary will do about it," said the senator, who was briefed on the draft report. "If people cooked the books, manipulated the methodology or told the contractor to ignore the rules, those individuals need to take the heat."

If Congress spanks Medicare you can expect Medicare to spank providers with tougher audits.

All providers will suffer for the actions of a few - and for the actions of a watchdog agency that tried to cut a few corners.

What Alternatives for Physical Therapy?

The Outpatient Therapy Payment Alternative Project Synopsis is at the point of data collection...

"In order to collect the needed data, the project involves (1) the development of a data collection strategy, including the recruitment of therapy providers to participate in data collection..."

The Project needs to collect data on how to measure the patients you see in physical therapy every day.

Medicare would like to know three things

1. How disabled are they?
2. How much will they improve with physical therapy?
3. How disabled will they be at discharge?

"The Medicare Payment Advisory Committee (MedPAC), the Government Accountability Office (GAO), and outpatient therapy stakeholder organizations have suggested that the claims and administrative data currently available to CMS are not sufficient as the basis for developing better alternatives to the therapy caps."

Right now, the data collection instrument looks like it will be the Activity Measure for Post Acute Care (AM-PAC).

"the AM-PAC was designed to be used across patient diagnoses,
conditions and settings where post acute care is being provided"

.
I currently use the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) and I like it.
This project may dovetail with other projects ongoing at Medicare.

The Physician Quality Reporting Initiative (PQRI), affectionately known as Pay for Performance (P4P)may become a part of the Alternative Payment Model.

The American Physical Therapy Association (APTA) is working on a payment model (an alternative to the 'Alternative') that will pay providers more when the patient gets better in less than the expected number of visits.

"Value Purchasing in Outpatient Physical Therapy" by Alphonse Amato, PT, MBA in 2006 laid out a similar-sounding plan.

Go read it.

It sounds like a blueprint for the future.

Depends on who gets their way.

Developing Outpatient Therapy Alternatives

I just participated in an open-door session with the company that contracts with Medicare to develop a new way to pay physical therapists.

The firm, RTI International, has developed a web page called Developing Outpatient Therapy Alternatives that will have resources for clinicians to study an anticipation of the new measurement instruments.

On August 13th, the podcast of today's free, two-hour open door session will become available and I will post of provide a link here.

The new payment system is designed to prevent a re-occurrence of the Congressional/Executive S.N.A.F.U. on July 1 that I blogged about here, here and here.

Bottom line, the new payment system is seeking a way to 'risk adjust' patients so that Medicare can pay $50 for a simple ankle sprain and $2000 fro a complicated rotator cuff rehab. These numbers are make-believe but they make the point.

Consider for example two patients - each has the diagnosis 724.4 (Lower Back Pain). All Medicare has now is data from the claim form: that is the diagnosis 724.4 and the billed charge.

By the way, 724.4 is not a physical therapy diagnosis, it's just a CPT code that conveys little actual information.

Medicare would like information that helps them do the following:

1. Anticipate cost
2. Know how bad the patient is
3. Know how long the patient will be seen
4. Know how much better the patient will get

The new measurement instrument would most likely be a paper or web-based questionnaire that the patient and the clinician fill out together and update regularly, possibly as part of the Medicare Progress Note (every 30 calendar days or 10 treatment session - whichever is less).