Bulletproof Expert Systems on PT Talker with Jeff Worrell

Jeff Worrell has interviewed a cross section of the world's top physical therapists and rehabilitation experts on his podcasting website PT Talker.

And, now its my turn.

Jeff and I spoke for just over 15 minutes about my new book Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting.

Like most good interviewers, Jeff cut through my verbosity to get to what physical therapists really care about:

• How can you run your clinic more efficiently?
• How can you make more money, or
• How can you make your job easier? 

My book describes documentation systems, both paper-based and electronic, that attempt to do just that.

Specifically, I discuss how physical therapists in outpatient practices can...

• Produce superior patient-based outcomes.
• Generate a Medicare-compliant note quickly and without excessive narrative writing.
• Create "prompts" that remind the therapist when a specific data point, test or note is called for.

You can order the book at a 40% discount off the retail price here.

Thanks, Jeff, for helping physical therapists do more of what we do best.

The Value of Physical Therapy: Reimbursement Can Increase 160% Before We Hit a "Break Even"

A new 6-month cost-effectiveness study of 515 musculoskeletal pain patients treated in a self-referred, direct access Welsh system found that the gains from primary physical therapy treatment of injured workers dramatically outstripped the costs.

The costs varied from £194 to £360 (about $300 to $569) per episode of care.

The gains received were £1,386 to £7,760 ($2,180 to $12,261).

Note that the gains DID NOT include wider societal effects of physical therapy rehabiliation, including:

• reduced sickness benefits costs
• reduced costs to employers attributed to improved production
• reduced absence rates from work

All measured outcomes improved over the 6 month treatment period, including...

• standardized functional scores
• psychosocial vartiables
• pain
• work loss and
• medical resource use

However, since this was a small study with no control group and no randomization the treatment effect could not be exclusively attributed to the physical therapy.

The authors results, however, indicated that, based on prevailing payment rates for physical therapists in Wales and the social value of preventing musculoskeletal injuries on workers' quality of life the following conclusion could be made:

"Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user."

More studies like this need to be done that measure the cost effectiveness of surgery, injections and pharmaceuticals in the treatment of musculoskeletal pain syndomes affecting workers.

This study was published on the 23rd of February, 2012 by BMC Musculoskeletal Disorders.

Cognitive Behavior Therapy Over the Telephone Effective for Chronic Widespread Pain

Physical therapists who treat chronic pain patients may be interested in this new randomized controlled trial of 442 patients comparing cognitive behavioral therapy (CBT) and an exercise program over 6 months.

As background information, the researchers described why alternatives to pharmacologic management, such as CBT and exercise, are necessary:

"In the United States, mean per-patient costs, including the following:

• pain and non-pain-related medication,
• physician consultations, 
• tests and procedures, 
• and emergency department visits 

...in the six months following a new diagnosis of fibromyalgia were $3,481"

The researchers compared telephone-delivered cognitive behavioral therapy (TCBT), graded exercise, combined intervention, or treatment as usual (control group). The results are shown in this chart:

Rate of Positive Outcomes
Time Frame	Control group	TCBT group	Exercise group	Combined Exercise and TCBT
6 months (end of intervention)	8.1%	29.9%	34.8%	37.2%
9 month follow-up	8.3%	32.6%	24.2%	37.1%

Cognitive Behavior Therapy...

"...represent a management strategy that puts patients firmly in charge.  

The skills learned in CBT, for example, are available after hours and over long weekends and do not require monthly refills

Moreover, because CBT can be administered by telephone, this intervention is convenient and can be made available to a wide range of patients."

The implications for physical therapists practicing in "traditional" settings with standard techniques and interventions are these:

1. Notice the deterioration of exercise-only 9-month outcomes - we know this to be true since most patients don't stick with their exercises once they start feeling better.
2. The TCBT group treatment were delivered over the telephone - this new delivery method is a threat to our traditional, clinic or hospital-based delivery and payment structure.
   
   
3. Presumably, similar technologies such as the following:

• Voice Over-Internet-Protocol (VOiP, or Skype),
• Simple Message Syndication (SMS, or text),
• social networks or
• old-fashioned e-mail

...could work just as effectively.

I'd be curious to hear about therapist treating chronic pain patients using Cognitive Behavioral Therapy. I would like to learn some of these techniques.

I believe behavior-based interventions using non-traditional delivery methods represent the future for our profession.

Thoughts?

Improper Payments the Focus of Obama's Speech

President Obama, in his Wednesday, March 10th, 2010 speech in St. Louis, Missouri, unfortunately chose to focus on Medicare inefficiencies and the estimated $100 billion dollars in 2009 improper payments as the main means to cost control and a way to pay for his proposed reform efforts.




Worse, he chose to laud the Recovery Audit Contractors (RACs) as potential saviors of healthcare and a major source of cost savings in his healthcare reform proposals.

The Improper Payments Elimination and Recovery Act (originally introduced in 2009) is designed to introduce RAC-style auditors to other, high-cost areas of government spending, like military defense and education.

When, in fact, the problem is not mainly inefficiencies in payment but the system itself: fee-for-service creates incentives to overutilize, overspend and overtreat.

Obama's health care reform has been appropriately criticized as health care financing reform.

An outcomes-based system for medical payments is years away and the transition is likely to be gradual and phased-in.

America has the highest health care 'unit prices' in the world but a middling rank in total outcomes (#34).

Rather than cast auditors as heroes (which, by contrast, paints doctors, hospitals and physical therapists as villains) let's put our efforts into accelerating the transition to real health care reform - outcomes.