Why Physical Therapists Should Make Diagnoses

"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the American Medical Association from John Barnes
CEO, American Physical Therapy Association

12/22/2009

Marcus Welby is Dead

"It's the death knoll of the private practice..." said Kurt Mosley, vice president of strategic lliances for Merritt Hawkins and Staff Care, a nationwide healthcare staffing organization.

"...I think... nobody wants Marcus Welby any more."

"That concept doesn’t play anymore and it’s not effective."

Recruitment of physicians into private practice is now only 1% of all physician recruitment activities.

"It’s not necessarily that surprising, but it dropped so dramatically (this year)."

This article from Healthcare Finance News sources Mosley's statement and provides additional links to explore these changes in physician recruitment.

Marcus Welby, MD was a television show about a gentle family physician in a private practice in Santa Monica, California. The TV show ran from 1969 to 1976. The 1970 season was the very first #1 hit show for ABC networks.

Marcus Welby, MD delt with sensitive medical issues, such as depression, brain damage, breast cancer, sexually transmitted diseases, epilepsy, leukemia and Alzheimer's Disease.

How Do Physician Employment Trends Impact Outpatient Physical Therapists?

Fundamentally, physical therapists' practice and physicians' practice are different.

Physicians require access to sophisticated testing, technology and the resources of the acute care hospital to practice effectively in these medern times.

Physical therapists may also need access to hospitals, but to a lesser extent than physicians (which helps explain why physical therapists are not included in Meaningful Use incentive payments for providers who purchase Electronic Medical Records and achieve interoperability with hospitals).

This American Physical Therapy Association (APTA) letter to the American Medical Association (AMA) nails the point, exactly:

"Doctors of physical therapy are not medical doctors, and medical doctors are not doctors of physical therapy.

Physical therapy is not a subspecialty of the medical profession.

Physical therapists provide a unique but complimentary service that physicians are untrained to provide."

Trends affecting medical doctors could buffet private practice physical therapists but seem unlikely to put the nail in the coffin of private practice physical therapists the way some are predicting for medical doctors.

I think the future is bright for private practice physical therapists. Its not a future like those who went before us, like Marcus Welby.

It could be better.

Physician Decision Making "Can't be Trusted" for Organ Transplants

Physicians, in their own words, "gamed the system" for organ transplants and "can't be trusted".

To be fair, physicians were acting in the interests of their individual patients. But, other patients and society in general were the losers.

The ethics and the economics of organ transplants are emotionally fraught and complex. Better to listen to this Planet Money NPR podcast.

Direct Access to Physical Therapists Can Reduce the Physician Shortage

Think physical therapists have it rough because our patients don't have direct access to our services?

State laws preventing direct access to physical therapist services still exist in four states:

• Alabama
• Indiana
• Mississippi and
• Oklahoma 

But, this recent article in The Atlantic by John Rowe, MD and professor at Columbia University exposes the plight of nurses and the political hypocrisy of physician organizations.

"...nurses are only permitted to practice independently to the full extent of their training and competence in 16 states and the District of Columbia. The remaining states (34) impose regulatory barriers that limit their scope of practice."

A 2010 Institute of Medicine (IOM) report on Advanced Registered Nurse Practicioners (ARNP) found...

"...the report concluded that properly trained APRNs can independently provide care primary care services as effectively as physicians."

But, according to Dr. Rowe, attempts by nurses to expand their scope of practice are blocked by physician organizations at the state level, such as...

• The American Medical Association
• The American Osteopathic Association
• The American Academy of Pediatrics
• The American Academy of Family Physicians

Social and cost pressures are growing to allow nurses greater decision-making authority. Physical therapists should also participate in this "flattening of the medical hierarchy".

But, physical therapists need to first practice more like primary care providers by providing basic screening care, like measuring blood pressure, according to this new study by Diane Jette and Dianne Jewell in the April Physical Therapy Journal.

Listen to PTTalker interview Dr. Jette here.

The problem is that physical therapists don't see themselves replacing physicians as primary care providers According to Drs. Jette and Jewell...

"...physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome."

Further, physicians cannot and perhaps should not be asked to provide all of these services.

Zeke Emanuel, MD, PhD argues in the May JAMA that we should "Shorten Medical Training by 30%":

"Years of training have been added (to the physicians' curriculum) without evidence that they enhance clinical skills or the quality of care.  

This waste adds to the financial burden of young physicians and increases health care costs.  

The average length of medical training could be reduced by about 30% without compromising physician competence or quality of care."

There will be no physician shortage in America - not if physical therapists can step up.

And I think we can.

Comments?

12 weeks of Physical Therapy Required By New Medicare Guidelines Prior to Joint Replacement in Florida

Medicare has begun to deny hospital charges for total joint replacement surgery IF the surgeon has failed to implement up to 12 weeks of pre-operative PT and/or bracing, according to Vincent Hudson, CEO of the medical consulting practice PMC, Inc.

"Medicare A has denied payment to hospitals, and I am sure will trickle over to physicians.  

This new standard should be increasing the numbers of referrals we see from Medicare.  

As in most cases, I expect to see other commercial insurances to follow shortly.  

Make your referring physicians aware of this, as hospitals have already begun to do so..."

Vincent made his comments on March 20th on LinkedIn in the Physical Therapists in Private Practice group.

This agressive new program in Medicare Audits is threatening physician and hospital reimbursement for total joint replacements and lumbar spine fusion in many states across the country.

The expanded use of Medicare Administrator Contractor (MAC) pre-payment audits has placed a premium on documentation in the hospital record and may threaten reimbursement for physicians with poor documentation skills.

On November 15, 2011, CMS announced three new 3-year demonstration projects (reported here by PTD). The Recovery Audit Prepayment Review Demonstration is designed to help curb improper Medicare and Medicaid payments.

As proposed, the demonstration would allow Medicare recovery auditors to review claims after services are provided but before the claims are paid to ensure that the provider complied with all Medicare payment rules. This would prevent improper payments before they are made.

Seven states with high populations of fraud- and error-prone providers are targeted

1. Florida
2. California
3. Michigan
4. Texas
5. New York
6. Louisiana
7. Illinois

...and four states with high claims volumes of short inpatient hospital stays are targeted.

1. Pennsylvania
2. Ohio
3. North Carolina
4. Missouri

As designed, this program would affect almost half of the Medicare population.

The contractor for MAC jurisdiction 9 is First Coast Service Options (FCSO), which includes Florida, Puerto Rico, and the Virgin Islands. FCSO developed a local coverage determination (LCD) on total joint replacements.

The original draft LCD included a requirement that multiple 12-week nonsurgical interventions, such as physical therapy, be documented prior to surgical total joint replacement.

Revisions to the LCD now require only one non-surgical intervention, such as 12 weeks of physical therapy.

Weeks later, the MAC announced a new prepayment audit of 15 specific DRGs, 4 of which are orthopaedic codes, including those that cover total joint replacements.

"As with the Total Knee replacement, the medical record documentation must indicate continued symptoms following medication ....there also must be documentation of a trial of physical therapy and/or external joint support provided equal to or greater than 12 weeks..."

I agree with Vincent.

Get out there and educate your physicians, especially your family practice docs and your unaffiliated orthopedic surgeons who will want to avoid denials.

They'll appreciate the heads-up.

Physical Therapy Services Billed by Physicians in Florida Have a High Error Rate

Services billed by physician specialties represented 70% of the dollars incorrectly paid for physical therapy services in the November 2011 Comprehensive Error Rate Testing (CERT) Report.

Additionally, past medical review experience has identified high claim error rates when therapy services are billed by physicians.

The most common reasons for an error to be assigned are the following:

• insufficient documentation
• failure to meet Medicare’s documentation requirements specific to physical therapy services
• failure to meet medical necessity guidelines.

Therefore, based on high error rates validated through CERT findings and FCSO’s data analysis, a prepayment medical review edit for physical therapy claims billed by physicians in Florida will be implemented on March 19, 2012.

This prepayment edit will require submission of medical records to support physical therapy services billed by physicians.

More information can be found at the First Coast Service Options web site.

We discussed Medicare Audits here and the high CERT error rate for Chiropractors here.

Electronic Health Records May INCREASE Uitilization of Diagnostic Imaging

Contrary to the notion that Electronic Health Records (EHR) will lower spending a new study in the March Health Affairs found a 40% to 70% INCREASE in ordering of second x-ray or CAT scan. EHRs are supposed to lower health care spending by improving physician access to a patient's medical history and diagnostic test results.

Read the Health Affairs article here.

A "convenience effect" may be the mechanism by which EMRs lead to increased imaging.

Physicians have the ability to review results much more quickly and without having to track them down from an imaging facility.

"The effect may be to provide subtle encouragement to physicians to order more imaging studies".

Referring to better access to results with computerization, lead author Danny McCormick, MD says,

"As with many other things, if you make things easier to do, people will do them more often."

You can also read this summary article from Fierce Healthcare.

One implication for physical therapists might be an increased need for critical pathways like the Starbucks/Virginia Mason model from 2006 or the Intel/Cigna model from 2011 in order to contain the overutilization of diagnostic imaging.

Management and Measurement of Primary Care Physical Therapy

I'm sure the BEST primary care physicians in America are consistently measuring this important clinical variable in their older patients as a predictor of mortality and a gauge for the medical necessity for certain services, such as physical therapy.

However, I'm even more sure that MOST physical therapists are using this important clinical tool.

Physical therapist managers may even use 10' Gait Velocity to improve their clinical documentation and prevent a Medicare Audit.

This television news report shows how walking speed measurement is becoming more contemporary.

 

The August 2009 Journal of Geriatric Physical Therapy paper titled Walking Speed: The Sixth Vital Sign presents a helpful graph that I recommend every physical therapist manager include in their therapists' toolkit.

This 2001 Journal of the American Medical Association (JAMA) paper describes how the best academic physicians are beginning to recognize the value in documenting and treating slowed gait in elderly people as a primary source of disability.

I'd like to see the 10' Gait Velocity (Walking Speed) tool used as a screening device in a primary care setting that might allow physical therapists to do the following:

• assess populations of patients eligible for treatment
• score their risk for a future fall or disabling condition
• treat them proactively or refer them, as necessary
• and lower future health care costs.

Who else thinks this is a good idea?

Do We Need Physical Therapists or Algorithms?

"Do you use Treatment Based Classification algorithms?" I asked my friend in Florida. 

"No", she replied.  

"Why not?" I asked. "

If I use an algorithm, where's the need for the physical therapist?" was her final answer.

My friend is a busy, private practice owner who is well-respected for her focus on the patient and her clinical skills.

Physicians, too, resist using computer algorithms to inform treatment decisions for similar reasons.

I've discussed this trend before, most notably in response to the surprising results at the Oxford Debate at the 2011 American Physical Therapy Association Annual Meeting in Washington DC where student physical therapists lead the room AGAINST clinical decsion rules.

Now, Vinod Khosla, tech investor and CEO of Sun Microsystems, questions whether Do We Need Doctors or Algorithms?

Essentially, Vinod's argument boils down to the fact that computers and computer algorithms are faster, cheaper and less likely to make a mistake.

Humans, on the other hand, are non-perfect and non-perfectable.

The odds are against physicians and physical therapists if we try to pit human productivity and human efficiency against machine productivity and machine efficiency. But, healthcare is NOT just productivity and efficiency. Healthcare is also caring.

According to Jeremy Rifkin in The End of Work:

"...the role of humans as the most important factor in production is bound to diminish in the same way that the role of horses in agricultural production was first diminished and then eliminated by the introduction of tractors".

I think physical therapists are in good position to incorporate decision algorithms into our practice WITHOUT losing jobs.

Humans still prefer to be cared for by other humans. Chris Anderson author of The Long Tail, describes algorithms, like Wikipedia or Google as:

"…operating on the alien logic of probabilistic statistics - a matter of likelihood rather than certainty....our brains aren’t wired to think in terms of statistics and probability. 

We want to know whether an encyclopedia entry (or a doctor) is right or wrong. We want to know that there’s a wise hand (ideally human) guiding Google’s results. We want to trust what we read.”

Physical therapists are among the most trusted of healthcare professionals. Besides, we work with our hands and we still touch the patient.

I don't think Vinod has an algorithm for that.

Provocative Position by American College of Physicians Calls for "Parsimonious Care"

The American College of Physicians (ACP) issued first-of-its-kind guidelines specifically calling for "parsimonious care" Monday.

Listen to the National Public Radio (NPR) interview here.

The 6th Edition of the ACP Ethics Manual is not a Clinical Practice Guideline so no direct implications are implied for physicians' practice patterns.

In other words, physical therapists shouldn't expect the kind of dramatic shifts in patient referral patterns suggested by the Virginia Mason/Aetna or the Intel/Cigna critical pathways much discussed lately.

But, this is the first time that ANY medical society has advised their physician members to consider cost when making patient care decisions. From the Manual:

"In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches."

Some people are concerned about the word "parsimonious". They are concerned that this word has a negative conotation that, in the polarized debate over heathcare reform, could be associated with rationing care. As used in the Manual...

"Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."

For physical therapists, information on the most efficient care will most likely come from comparative effectiveness studies.

In high-volume conditions such as lower back pain and arthritis guidelines will likely support a shift away from routine imaging, invasive testing and surgical treatment.