Stark Loophole not the only bright light in the new MedPAC report

The new MedPAC Report to the Congress: Aligning Incentives in Medicare is gaining attention amongst physical therapists primarily for its recommendation to close the "Stark Loophole" but also should be credited for emphasizing the collection of clinical data as a condition of payment.


MedPAC suggested in its recent report that the US Congress remove outpatient therapy from its list of services qualifying for the "in-office ancillary services exception" because physicians are not using the exception for its intended purpose and because costs are climbing too quickly.

MedPAC also suggested collecting clinical data as a condition of payment, called Coverage with Evidence Development (CED).

I propose Medicare could deliver better OUTCOMES, save more MONEY and get better VALUE for beneficiaries and taxpayers if collection of clinical data is in place of burdensome, centrally-mandated process measures that waste time, generate excess paperwork and distract highly-paid and well-educated physical therapists from face-to-face interactions with their patients.

Asking physical therapists to examine, evaluate and record patient data is 100% in line with the Guide to Physical Therapist patient management model.

Coverage with Evidence Development could be a positive force leading to a change in physical therapist culture: a shift to a culture of measurement.

If CED were in place of arbitrary process measures as a condition of payment then we could reduce Medicare audits by accountants and lawyers.

However, if CED is just one more centrally-mandated and administrated process measure then we'll all just be working harder.

PT Assistants and Effectiveness of Treatment Outcomes

(Special thanks to Shannon Wills for guest hosting this post.)

The power of an effective and complete physical therapy program has to be experienced to be believed.

I should know what I’m talking about because I went from walking with crutches to playing racquetball at full strength in just 8 months, thanks to the intense physical therapy rehabilitation program I underwent.

Therapy helps you regain normal movement in your joints and other parts of your body after an accident or an injury; it helps you re-learn habits that are part of your daily routine, but which your brain has forgotten because of a stroke or other illness. Some programs can be done on your own, while others need the intervention of a qualified therapist or a physical therapist assistant (PTA).

Physical therapy is only as effective as the combination of the program that is designed for you, the therapist you’re working with, and most important of all, your efforts and dedication in adhering to the program without any excuse whatsoever.

So, if you’re allowed to choose between working with a physical therapist and a PTA, you’re definitely going to choose the former if you know a little about the hierarchy in this field. The reason is simple – why choose a nurse when the doctor is available?

PTAs are good at what they do no doubt, but while they can carry out treatments, they cannot reassess the patient on a daily basis, make diagnoses, or change the program of treatment based on the progress or prognosis of the patients. This could inhibit the recovery of some patients who would probably do better if their program was altered a little or if their routine was stepped up or down.

So when we look at the effectiveness of the outcomes of treatments that have been carried out by PTAs, we find that the quality of care decreases because the PTAs in charge are limited by their experience and the educational qualifications.

Predictors of Physical Therapy Clinic Performance in the Treatment of Patients With Low Back Pain Syndromes by Resnik, Liu, Mor and Hart provides evidence towards the same – a group of clinics that participated in the research found that in the treatment of patients with lower back pain syndromes, clinics that use PTAs sparingly provided superior quality of care.

While the outcome of this research does not mean that PTAs are not good at their jobs, it only goes to prove that a therapist has to be involved in the treatment at all stages, especially during the initial period of rehabilitation when it is easy to gauge the effectiveness of the therapy program and how the patient responds to it.

By-line:
This article is written by Shannon Wills, who writes on the topic of Physical Therapy Assistant Schools .

Make your comments to this blog or e-mail Shannnon directly at shannonwills23@gmail.com .

Spanish OPTIMAL available for Physical Therapists

I like the OPTIMAL scale.

I use it enough to need a spanish translation - you can get a copy of it here (Links or Forms page).

Remember to request copyright permission from the APTA to use it in your clinic.

Like many things, it is not a perfect solution for outpatient physical therapists looking for outcome scales.

The shortcomings of the OPTIMAL are well-described here.

The best critique of the OPTIMAL is that better alternatives exist.

Like a 50-year old dowager waiting for perfect love the quest for 'the one' can leave us frustrated.

Since only 48% of physical therapists currently use outcomes measures it seems like many PTs are waiting for 'the one'. (PHYS THER 2009 89: 125-135)

This spanish version is not 'the one' but it may be a step closer to getting a majority of physical therapists to use outcome measures.

“If I could wish for my life to be perfect, it would be tempting but I would have to decline, for life would no longer teach me anything.”

- Allyson Jones

What does an outlier look like?

Well, this is a bit of a stretch even for TBC PT geeks...

What an outlier looks like...

Enjoy.

Tim

Are 'home grown' outcomes measures better than OPTIMAL?

For now, over half the physical therapists in the US can take comfort in their 'informal collection of data' rather than their use of standardized outcome measures.

They are in the majority.

A new study by Dr. Diane Jette in the February Physical Therapy Journal titled Use of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and Applications reveals that only 48% of physical therapists in the United States used standardized outcome measures.

For now, they are in the minority.

Similarly, only 40% of the physical therapists in New Zealand appear to use outcome measures.

For the present, there is no mandate that physical therapists use standardized outcomes measures to assess patients at baseline.

Instead, physical therapists seem to act based on a professional consensus which indicates a lack of solidarity on outcomes measures.

Rather than a mandate, Medicare 'recommends' the use of one of three outcomes measure to assess need and clinical progress in patients.

"Home grown" measures instead

Dr. Jette's study found that 'home grown' outcome measures are used by a surprising 22% of physical therapists.

Why use 'home grown' measures?

Are they better than one of the 'recommended' tools?

Are 'home grown' outcomes measures better than the OPTIMAL?

Physical therapists can use baseline outcome measures to direct the plan of care and increase the thoroughness of their evaluation.

Dr. Jette's article illustrates the essential limitation of all outcome measures:

Most clinicians do not see the value in using standardized outcome measures.

The dilemma of the outcomes measure value proposition leads to this premise:

Outcome measures are a policy-makers' solution to a problem faced by clinical physical therapists, namely:

"How do I know what my patient needs?"

Bottom line, policy-makers need a way to measure value for the $3.06 billion (2006) annually spent on Medicare outpatient physical therapy.

The majority of physical therapists will need to quickly adapt when mandated outcomes measures arrive within five-years time.

Then, it will be time for 'home-grown' to go home.

What will replace the OPTIMAL?

I get a lot of feedback on this blog from physical therapists who don't much like the OPTIMAL scale.

Some say they use it because it's 'recommended' by Medicare, not because it's a good outcomes scale.

Some of the problems with the OPTIMAL scale that physical therapists relate to me are:

• Too general
• No descriptors of the activities (eg: long distance walking)
• Inappropriate for elderly persons (eg: running, hopping and jumping)
• Too long (21 activities)
  

This is just a short list...

Additionally, the American Physical Therapy Association has gone on record saying the OPTIMAL has not fulfilled its intended mission:

...to be the single, disease-specific treatment planning and goal-setting tool for outpatient physical therapy Medicare compliance and outcomes measurement. (my emphasis)

Nevertheless, the APTA maintains the OPTIMAL page on its website and offers free licensing for clinical physical therapy use until a superior alternative is found.

What are the alternatives?

Now, be aware that these are commercial (NOT free) alternatives that offer some enhancement over a pen-and-paper tool like the OPTIMAL.

CARE tool (May 2009)

AM-PAC (required by 2012?)

FOTO

There may be others, like the following:

• Neck and Back Index
  
• Oswestry scale
  
• Lower Extremity Functional Scale
  
• Patient-Specific Functional Scale

...and others, that are acceptable overall outcomes measures but are not recommended by Medicare.

Acceptable outcome measures have usually gone through the peer review process and are published in a professional journal and are accepted by a consensus.

What is the trade-off?

The trade-off for comprehensiveness is time.

A tool that is disease-specific requires multiple templates for different body parts or regions (eg: Neck and Back Index).

A tool that is more comprehensive is longer and harder for the patient to complete.

A longer tool may be more difficult for the clinician to score.

A commercial tool, today, offer few benefits over the free tool.

The OPTIMAL is brief and simple to score.

My own recommendation, today, is for the clinician to use the OPTIMAL.

What is the time frame?

In May 2009, Research Triangle International (RTI) will begin a pilot project to develop a new measurement tool to find

"...better information tied to patient need and the effectiveness of outpatient therapy services."

Between 2012 and 2014 the pilot project will wrap up and, presumably, physical therapists will have a needs-based, risk-adjusted tool to assess their patients, in acute, hospital-based and outpatient clinics.

What if you do nothing?

Even if you don't adopt a commercial tool today that, realistically, will segue into the recommended tool by 2012 you should be using the free tool.

Doing nothing is not an option.

A Medicare auditor looking at your files may consider the absence of any outcomes tool as 'blatant disregard' of published recommendations.

Get your systems in place now.

The easiest, simplest system today is the OPTIMAL baseline and follow-up scale.

Use outcomes measures to measure your effectiveness because it's good physical therapy.

Use outcomes measures to improve your Medicare compliance because you can't afford not to do so.