Why Can't Connor Ride His Bike?

My eight-year old son has a friend named Connor. Connor is a normal eight-year old boy except in one respect.

Connor can't ride his bike.

Connor is in physical therapy at school working on gross motor control, lower extremity strengthening, jumping, hopping and climbing activities. I've seen Connor run - he's a bit slow but otherwise normal. Jumping is a bit awkward but he makes it. Hopping is status quo.

So, why can't Connor ride his bike? Why does he walk when all the other neighborhood kids ride by - leaving him pushing his bike?

It turns out that Connor is scared of falling off of his bike.

Connor fell of a smaller bike when he was two years old and broke his arm. He has been scared to ride his bike ever since. His mom has asked many of the neighborhood dads (even Connor's karate instructor) to help Connor get over his fear. I've tried to work with him a few times.

Connor seems to demonstrate what Hart et al describe as...

"Evidence (of the) possible existence of fear avoidance beliefs or pain-related fear in people who have other impairments or who may not have pain, perhaps because of learned behavior after previous painful episodes or misconceptions about pain."

In Screening for Elevated Levels of Fear-Avoidance Beliefs Regarding Work or Physical Activities in People Receiving Outpatient Therapy in the August Physical Therapy Journal Hart et al found that fear avoidance beliefs can be described as High or Low (rather than a score) and that one screening question can measure the level (rather than 21 questions in the Fear-Avoidance Beliefs Questionnaire - FABQ).

What Can You Do?

Physical therapists can find out if musculoskeletal pain patients have elevated fear-avoidance beliefs early in the course of care so that reducing the level of fear-avoidance becomes a goal of therapy.

The fancy term for reducing fear-avoidance beliefs is Cognitive Behavioral Therapy (CBT) which is a distinct psychological specialty but one from which physical therapists might be able to learn some management strategies for chronic pain patients.

Hart et al recommend the first step is to screen your patients for high levels of fear-avoidance with these two, simple statements:

1. "I should not do physical activities which (might) make my pain worse."
2. "I should not do my normal work with my present pain."

Statement #1 predicts the response (high/low) on the Physical Activity sub-scale. Statement #2 predicts the response on the Work sub-scale.

We've used the FABQ (21-item) but now I'm making these statements a part of my intake patient (self-report) forms that will be indicated with checkboxes indicating agreement or dis-agreement.

Co-morbid factors like fear-avoidance, age, depression and self-reports of function turn out to be bigger drivers of chronicity, cost and resource utilization (eg: PT visits) than traditional impairment measures like strength, ROM and swelling.

Physical therapists may be able to improve overall patient management and increase reimbursement by screening for fear-avoidance at the first and last visit.

Just as important, we may be able to more accurately detect those at risk - those people like Connor.

Mo' money

Treating fear-avoidance early in the course of care may allow physical therapists to 'risk adjust' an episode fee capped at, for instance, ten visits for uncomplicated lower back pain.

Today, all of your Medicare visits are reimbursed fee-for-service (FFS) but nobody expects Medicare FFS to last much longer in its present state - nor is Medicare FFS sustainable if it does last past this current legislative session.

Al Amato, PT wrote an article in IMPACT (PPS log-in required) called Value Purchasing in Physical Therapy in March 2006 that described the effect of risk adjustment on an alternative payment system. Mr. Amato wrote...

"Risk adjustment allows the comparison of a patient with a specific profile to a similar risk-adjusted group of patients in a large database.

This allows the ability to predict the efficiency and effectiveness of an individual treatment because of the profile of the similar risk-adjusted group of patients from the national database."

In the future, you will need to identify which patients are likely to have poorer outcomes (based of elevated fear-avoidance beliefs) but you will be able to request more treatment sessions. Or, you can treat the elevated fear-avoidance beliefs from baseline, get the patient better in fewer visits - and get paid a bonus.

Who Could get Better by Learning About Fear?

In 2007, there were 97,900 outpatient therapy providers billing the Medicare program in the United States: about 19% of these are Occupational Therapists and 7% are Speech Language Pathologists (table 7 & 10).

The intent is to transition all of these providers to a 'value based' payment program that allows providers to succeed and patients to get better.

Hart's study is a big step in the direction of value-based payment (Hart and Amato work for the same company) because this study shows clinicians how to quickly and accurately screen people like Connor for elevated fear-avoidance beliefs.

Improved screening for this, and other, psychosocial factors that influence chronicity can improve the effectiveness and efficiency of our physical therapy treatments.

'Skilled' Physical Therapy still not settled

'Skilled' physical therapy has been buzzing about lately - if you were lucky enough to catch the Rothstein Debates at PT 2009 in Baltimore then you may already be aware of what I'm about to tell you.

A new report from Developing Outpatient Therapy Alternative (DOTPA) describes, in excruciating detail, the distribution of $4.3 billion dollars paid for Medicare outpatient therapy in 2007.

The report also shows who billed what, for who and where. Without getting into the gory details (I don't want to spoil the ending for you) there are some data here that may give us some insight into physical therapist 'skill'.

This first table shows claim lines while the second table shows payments. Note the columns to the right, labeled 'PTPP' and 'Physician' (POPTs).

click the image to enlarge

This second table shows very much the same pattern in payments.

click the image to enlarge

I'll break it down a little more by carving out the rows for 'Ultrasound', 'Electrical Stimulation' and 'Massage Therapy'.

	PTPP	Physician
Claim Lines
Ultrasound	7.6%	10.6%
Electric Stim	2.8%	9.4%
Massage	1.0%	4.7%
Payments
Ultrasound	2.4%	4.2%
Electric Stim	1.2%	6.5%
Massage	0.7%	4.2%

I wonder what it is about the Medicare patient that demands twice as much ultrasound therapy when seen by a physical therapist employed by a physician?

Do patient findings drive 4-6 times as much electrical stimulation in a POPTs clinic as in my clinic?

Why are physical therapists even billing for massage? Oops! Maybe it's not physical therapists...

With all due respect to my peers who work in physician's offices - the numbers don't lie.

I don't know if the difference comes down to skill, dollars or undefinable but the implications seem clear.

Greater passive modality usage and fewer 'hands on' procedures leaves less room for physical therapists to practice their skills.

Get the full report from Developing Outpatient Therapy Alternatives (DOTPA) and Research Triangle International (RTI) here (Utilization Report 2009).

Betting on Physical Therapy Evaluations

I would bet that soon, physical therapy evaluations could be standardized for all outpatient settings.

For those physical therapists working in

• Inpatient Rehabilitation Facilities
• Skilled Nursing Facilities
• Home Health Agencies

...you may already have taste of standardized evaluations.

Depending on how much credibility you give public/private partnerships like the project called Developing Outpatient Therapy Payment Alternatives (DOTPA) you might wager on the success of their new tool.

DOTPA has created the same tool for all outpatients whether they receive physical, occupational or speech therapy.

Time to complete the tool is expected to be 15-30 minutes per patient.

The new tool will be modeled on the Activity Measure for Post Acute Care - Adaptive Short Form (AM-PAC-ASF) - lovely name, don't you think?

The tool will have separate admission and discharge forms.

The intent of the new tool will be to replace the arbitrary $1,840 therapy cap with a process that aligns payment with patient need.

Now, that's a bet I'll take.

Get details of the new DOTPA tool at www.optherapy.rti.org.

Faith and Physical Therapy

Today is Sunday, the 11th of January and faith is on on my mind.

"Now faith is the substance of things hoped for, the evidence of things not seen."
Hebrews 11:1

My first job in 1992 had me working with Mike, a physical therapist who would pray with his patients.

At the time I had no religion training and I didn't know quite what to make of Mike's non-traditional efforts to care for his patients.

Mike didn't pray with every patient, just those that seemed receptive and who needed that extra bit of inspiration to keep going and get better.

In 1992 neither Mike nor I had much knowledge of Medicare payment policy and so he would bill the patient for his time spent in prayer.

Today, of course, I realize that since prayer doesn't meet the criteria for physical therapy skilled services it shouldn't be paid for by Medicare or any third-party payer.

I tell this story because in 2006, Medicare spent $3.06 billion dollars on outpatient physical therapy services with no evidence that the services were any more skilled than Mike's prayer.

Now, maybe we all need a bit more prayer. I certainly pray more now than I did in 1992.

But, when we are talking about evidence of skilled decisions, we need to provide evidence that physical therapists' decisions matter.

Otherwise, we are no better (and no worse) than...

• massage therapists
• athletic trainers
• personal trainers
• 'kinesiotherapists'

...we are just more expensive.

Current efforts to improve physical therapists' decision-making tools come from several sources...

1. The Physician Quality Reporting Initiative (PQRI) - a much lambasted project begun in July 2007 to measure performance among healthcare providers. The project is cuurently establishing a baseline of over 100 variables that will gauge the health and function of Americans on such measures as falls risk, medication usage, pain, incidence of diabetic foot, body mass index and more.


2. Developing Outpatient Therapy Payment Alternatives (DOTPA) - kicked off in September 2007 with data collection set to begin in May 2009 this project aims to reduce the impact on setting (eg: home health, outpatient clinic, hospital) as a driver of payment.

The DOTPA project plans to develop two pen-and-paper outcome measures based on ambulatory status (walking and non-walking). The universal use of these outcomes measures will enable an 'apples-to-apples' comparison of patient outcomes across various settings.


3. OPTIMAL scale is one of the current professional consensus, Medicare-recommended outcomes tools for outpatient physical therapy. OPTIMAL is a broad outcomes measure that will enable the aformentioned 'apples-to-apples' comparisons.
   
   OPTIMAL is meant to be paired with a condition/disease specific measure such as the Lower Extremity Functional Scale, the Neck or Back Disability Index, etc.
   
   Yes, that means you may need to administer two seperate outcome scales to each patient.
   
   Other professional consensus, Medicare-recommended outcome tools are the Activity Measure for Post Acute Care (AM-PAC) and the Focus on Therapeutic Outcomes (FOTO)


4. The American Physical Therapy Association (APTA) provides continuing education on Medical Necessity and Medicare payment policy on a regular and convenient schedule.
   
   An encyclopedic resource on documenting skilled physical therapy services is the APTA's Defensible Documentation for Patient/Client Management


5. The Diagnosis Dialogs that are attempting to find descriptors (or labels) for physical therapists to describe the results of our clinical examination and evaluation. The descriptors/lables would be...
   

   "standardized anatomical, physiological or functional terms that concisely describe the condition or syndrome of the human movement system."

6. Edward's decison-making model shows how physical therapists decisions (and diagnoses) are different, complementary and equally important with physicans' diagnoses.


7. Bulletproof Physical Therapy Notes and Charts is my own effort to improve written decision-making through what I call competency-based compliance, that is, the intersection of evidence-based practice with Medicare payment policy.
   
   I've been working on Bulletproof for about two years and I have a book due out Summer 2009.

I haven't seen Mike in 10 years and I don't normally pray with my patients. I'm glad, however, that he showed me his example of patient care.

He showed me that his care, by his prayer, could be distinguished from his skill.

Hopefully, all physical therapists have stories of our care that may not show up on paper. There may be no evidence.

"Faith proves to the mind, the reality of things that cannot be seen by the bodily eye."

But now, we have new tools that can show our skill. We can justify the next $3 billion dollars spent on outpatient physical therapy. We can have evidence of the things we see in physical therapy.

What are your stories?