Physical Therapy, Silver Coins and Green Eyeshades

We need a common coin of the realm.

After Napoleon's final defeat at the Battle of Waterloo on June 18, 1815 the British bond market rallied as investors predicted lower government borrowing for future wars. Nathan Rothschild arrived in London just hours ahead of the news of the battle's outcome and began buying up British war bonds at bargain basement prices.

Bond prices rose as yields fell and Rothschild sold at a huge profit. Rothschild's future was made in those months following Waterloo. Many sources credit Rothschild as the pre-eminent banker, speculator and, some say, the most powerful financier of the nineteenth century.

After securing his fortune Nathan Rothschild went on to become famous and also managed to create a standard that still affects our lives today. He demanded, and got, due to his money and influence, a uniform system for paying bond holders in sterling silver - no matter which country they were from. Investors no longer had to go to London to receive their bond coupon payments and sterling silver became the coin of the European investing realm.

Improvements in payments made bonds more attractive to investors and, ultimately, easier for Rothschild to sell. Bond holders were better off, governments gained access to new funding and Rothschild got richer.

I see a parallel here.

Couldn't physical therapists demand a uniform measurement system for rehabilitation outcomes? If all rehabilitation professionals had a common measurement system (eg: standardized performance, self-report, impairment or classification measures) then physical therapist outcomes could be compared with other rehab professionals. Right now, the only available comparisons are based on setting (eg: POPTS, PTPP, hospitals, etc.) and the only available measure is cost.

What if physical therapists could compete with physicians on outcomes?

Physician owned physical therapy clinics (POPTs) are slightly lower in annual Medicare, per beneficiary costs ($522) than their Physical Therapist in Private Practice (PTPP) peers ($871) but that may be due to the 'Flying Below the Radar' effect.

Unfortunately, cost is not the best measure of competitiveness. Not if you believe that quality service is a better measure. WalMart competes on cost - would you buy healthcare from WalMart?

Physical Therapists under Automated Review

Right now, in America, powerful computer algorithms are sifting your claims data and looking for patterns outside the 'bell curve' - do you do a lot of manual therapy?

Four manual therapy units (1 hour) per visit? You are outside the curve.

Automated reviews, conducted by Recovery Audit Contractors (men in green eyeshades), are looking for duplicate payments like two spinal tractions in one day. Spinal traction is a 'supervised modality' - you set it and go treat another patient. Totally legal - however you can't charge more than one per day per patient.

Recovery Audit Contractors (RACs) made some good money in Florida, California and New York from 2005 to 2008 during the RAC Demonstration Audit with automated reviews.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

I posted this chart originally on June 8, 2009 from my own clinic data as well as US government published data from the RAC Demonstration Audit Report (June 2008)

I define 'good money' as the piddling amount RACs 'recovered' from me because cost/investment = $0 and return = $80. To the men in green eyeshades the calculated ROI is infinite.

Michael Apolski's Medicare Update blog is quoted in the September 2009 issue of Orthopaedic Practice Management - he discusses automated reviews on page 99.

"RACs can analyze claims using two methods. During “automated” review, they attempt to find “the low-hanging fruit” by making a claim determination at the system level without even reviewing the medical record, Apolskis says."

Alternative Physical Therapy Payments

The current lead contender for a 'common coin of the realm' is a tool being developed by a private-public partnership, Research Triangle Institute (RTI).

I have a couple of concerns with RTI's Developing Outpatient Therapy Payment Alternatives (DOTPA) project:

1. Despite their attempts at outreach they still have a government mandate - they can ram it down our throats, if they want to.
   
   
2. Their assessment tool is expected to take 15-30 minutes per patient! No time left for patient-therapist collaboration or establishing rapport.
   
   
3. Is RTI re-inventing the wheel? Physical therapists already know how to assess our patients - do we need a new setting-specific tool? Couldn't we do better with a set of condition-specific measures for common, high-volume conditions like the Oswesty for lower back pain or the SPADI for shoulder pain? Let the clinician choose.
   
   
4. How many physicians could manage the transition from profit-driven POPTs to outcomes-driven care? Would running a PT clinic under those circumstances (ie: when you're not a PT) be worth the 'hassle"?

Nathan Rothschild seized a singular moment in world history and used it to shape the future of finance - could physical therapists seize healthcare reform as a springboard to position evidence based physical therapy as the universal standard by which all rehabilitation professionals are judged?

Could we 'sell' physical therapy to a skeptical public of payers and government policymakers when we are all better off with outcomes?

Physical therapists should not take 'ownership' of physical therapy diagnosis

Physical Therapy Diagnosis is a blog I have posted to since about August 2007. Physical therapy diagnosis is also a topic I have been interested in since about 2005.

I first discovered PT diagnosis in reading the Guide to Physical Therapist Practice (2nd ed.).

The Guide had a reference to the Disablement Model by Nagi. Since then, Nagi's model has been updated by the International Classification of Functioning, Disability and Health (ICF) model which, among other things, replaces Nagi’s ‘functional limitations’ with ‘activity limitations’

The model describes how physical therapists can intervene by identifying the connection between measured activity limitations and measured limitations in body structure and function (Nagi's 'impairments').

Physical therapists identify the link and that process is the physical therapy diagnosis.

I can only say that I wish I had learned the disablement model in my undergraduate education. To say that my physical therapy practice patterns have evolved since adopting theis framework would be an understatement.

Not evolution, but revolution.

Imagine my surprise to learn that 'Physical Therapy Diagnosis' is a term not recommended for physical therapists by none other than the foremost author on functional assessment in physical therapy...

...Alan Jette, PT.

I found his 1989 article Diagnosis and Classification by Physical Therapists: A Special Communication in which he briefly discusses his thoughts on the matter...

"There are pitfalls along the way into which physical therapists might easily fall. One that particularly concerns me is the use of the phrase 'physical therapy diagnosis.' I concur with Sahrmann, who recommends that the term "diagnosis" be used by the physical therapist in referring to the identified condition that is the focus of the physical therapist's treatment. It should not be used to reflect ownership of the condition, which would be the inevitable consequence of using the phrase 'physical therapy diagnosis.'"

(Jette, 968-969)
I don't know how much has changed in the last 19 years...

Are we in danger of alienating ourselves from physicians if we persist in using the term 'physical therapy diagnosis'?

Has there been a surge in professional diagnoses?

• nursing diagnosis
• chiropractors diagnosis
• personal trainers diagnosis

It may be too late for me.

I've already taken a position on this issue. It's changed my life and my practice.

What about you?

Is Physical Therapy Valuable?

Physical therapists think that Medicare is run by bureaucrats (it is) but Medicare physical therapy policy is also set by bureaucrats (it isn't).

Years ago, I graduated from the University of Florida Physical Therapy Program with a Bachelors Degree in Health Science. I was trained in orthopedics and neurology. I was not trained in Medicare.

To get information from Medicare, in 1992, you had to do the following:

• call on the telephone


• ask your question


• wait while the bureaucrat looked up your answer in the Medicare Manuals


• gave you their interpretation


• implement your policy change

Fast forward to 2008 when, if you have a question about Medicare, you can open your handy electronic copy of Transmittal 88 using the Adobe Acrobat Reader (available for free) and plug in your question to the search bar.

Curious about Medical Necessity for Physical Therapy?

What exactly do the regs say?

A quick search (<5 seconds) returns 10 instances of 'Medical Necessity' in Transmittal 88. That should get you started.

But my original premise is that many physical therapists think the Medicare Manuals are written by bureaucrats without the patients' best interests at heart.

Why should physical therapists pay attention to policy written by bureaucrats (other than the police powers exercised by Medicare)?

Pay attention to this post by Larry Benz,PT posted at the Yahoo Groups PT Manager listserve

"The medicare superimposed rules have been written by beaurocrats (sic) and our profession has acquiesced or have had "small victories" that have been alluded to that only refine them.


At the end of the day, these additional "standards" cause increased monitoring costs and take away time from patients.
If the over regulated medicare rules become de facto as is being pursued by multiple folks within the PT world, there will not be a viable outpatient PT economic model."

The obvious answer is that bureaucrats don't write Medicare regulations in a vacuum.

Medicare consults with physical therapists like Rick Gawenda, President of the APTA Section on Administration and Steve Levine of the Rehabilitation Consulting and Resource Institute to implement changes to there Manual system.

The three 'bottom line' criteria that define a compliant Medicare plan of care are these:

1) Can the physical therapist demonstrate the medical necessity for physical therapy?

2) Can the physical therapist (or the PTA) demonstrate skilled therapy for each billed procedure?

3) Can the physical therapist show an expectation of a significant improvement in measurable patient function n a reasonable time frame?

If you do good PT the first time then there are no 'increased monitoring costs'.

Good PT begins with Physical Therapy Diagnosis, just like the physicians do it.

Value Centered Physical Therapy

This post comes from a thread in the Yahoo Groups PT Manager listserve between Rick Gawenda, APTA Adminstration Section President and Larry Benz, PT of MyPhysicalTherapySpace.com which discusses the perception that commercial insurance companies like UnitedHealthGroup are trying to emulate Medicare.

This is seen as bad by many physical therapists since Medicare is the most restrictive payer from the notes and charts compliance standpoint.

Medicare also has police powers. That is, if you mess up they may put you in jail.

If there is an organized attempt to model commercial insurance after Medicare then that is news to me.

But, come to think of it - why not?

If we hold Medicare as the standard-setting authority (since professional consensus and practice guidelines don't have any teeth) then could physical therapists follow just one standard?

Can we reduce the goals of the Medicare Manuals (like Transmittal 88) to their intended essence?

The more simple the interpretation of Medicare regulation the easier will be physical therapist compliance and the better will be patient care.

Correct me if I'm wrong (and I'm sure you will) but the Medicare Manuals (and their cousins the Local Coverage Determinations) are aimed at producing three things:

1) that physical therapists demonstrate the medical necessity of physical therapy in their charts and notes.

2) that physical therapists demonstrate that each intervention billed is skilled.

3) that the patient is expected to show significant improvement in measurable function as a result of the physical therapy.

Reimbursement aside, these criteria make for good physical therapy!

If student physical therapists (and old-school professionals) were trained to treat patients with these three criteria in mind then everybody would benefit.

- therapists would benefit from reduced documentation burden (drop the SOAP!)

- therapists managers and administrators would benefit from fewer regulatory constraints by following one standard.

- patients would benefit by increasing focus on measurable function and fewer symptom-oriented and pathology-oriented treatments.

- insurance companies (including Medicare) would benefit from greater transparency in physical therapy charts and notes.

When I graduated in 1992 from the University of Florida I had no training in the disablement model, in physical therapy diagnosis or in describing the medical necessity for physical therapy.

I thought the physician determined medical necessity! (maybe in 1992 they did).

Anyways, it's high time we standardized the 'rules of the road' for physical therapists and physical therapy managers.

If anyone is keeping score then they can count my vote for regulatory standards in physical therapy.