Why 'Quality' Care is Inevitable

In "Why 'Quality' Care is Dangerous" Jerome Groopman, MD complains the definition of 'quality' is too narrow, eg: only 'quality' that conforms to consensus standards set by Medicare experts is of sufficient 'quality'.

Consensus means measurement of simple clinical procedures that fail to capture the complexity of medical decision-making, such as diabetic management.

But 'quality' in P4P is meant to capture under-treated aspects of big, high-cost drivers in medicine, like why do so many people suffer from lower back pain (LBP)?

For example, pain is the number one reason people go to see a doctor. A simple zero-to-ten pain scale is more sensitive to clinical change than a comprehensive pain questionnaire yet pain is assessed in less than 50% of the clinical encounters in America.

Why?

One P4P quality metric for physical therapists is pain assessment and implementing a plan of care to treat pain.

Lower back pain has passed cancer spending in research dollars and, prior to 2006, small-dollar, high-volume CPT codes for therapeutic spine treatments were growing at over 35% per year.

Another simple problem in medicine:

Why are so many Americans obese?

Obesity, not disease, is the primary driver of disability in America.

Another quality metric for physical therapists is assessment of body mass index.

While Dr. Groopman could, no doubt, cite examples of complexity in medical decision-making involving LBP and obesity the vast majority of these cases are simple diagnoses that relate to lifestyle factors, not exotic diseases.

There's that old saw in medicine: "When you hear hoof beats, think horses - not zebras"

Show Me the Money!

The biggest, costliest health problems in America are not rare diagnoses - the costliest problems are the result of daily choices we make about diet and exercise.

Dr. Groopman is right, P4P simplifies the collection of basic data which may interfere with complex physician and physical therapist decision-making.

But, it's not the complex decisions American doctors needs help with...

We need help with the simple decisions.

The 'Old School' case for impairments

Call me 'old school'... (some folks have called me that, and more).

I still treat some impairments - it's how I was trained.

There is a certain amount of satisfaction in measuring a stiff joint, fixing it with my 'old school' physical therapy techniques and getting the patient better.

It makes sense.

Today, however, physical therapists measure patient characteristics that predict the treatment the patient should get.

We don't measure as many impairments anymore. Some of the measurement are not even 'physical' - now we measure 'fear of movement'.

These new measurements are better because they are predictive of the patient's ultimate outcome whereas impairments (eg: ROM, strength, etc.) generally aren't predictive of outcomes.

The new way makes sense, too.

Teaching an Old DogWell, this 'old dog' can still learn some new tricks, like...

• classification
• clinical prediction rules
• outcomes scales
• disablement models
• computer adaptive testing
• alternative payment systems

None of these concepts were taught in PT school in 1992 and, ironically, they weren't taught in any of my 'old school' continuing education courses at 'Marriott U.'

The New School

A new article in April's JOSPT shows, however, that some impairments are still worth measuring - BECAUSE they may be predictive of the patient's ultimate outcome.

Lentz, Barabas, Day, Bishop and George showed that the flexion ROM variable was the strongest contributor to shoulder function in a model that included variables such as...

• duration of symptoms
• sex
• age
• mechanism of injury
• average pain intensity
• flexion ROM
• Tampa Scale of Kinesiophobia

So, my 'old school' training may still be useful after all!

The Outcomes

While shoulder flexion ROM was the strongest contributor to shoulder (dys)function

"...the immediate clinical relevance of these findings was unclear."

In other words, does improving shoulder flexion ROM with my 'old school' PT techniques (stretching, joint mobs, manipulation, cranio-sacral (not), whatever...) lead to better outcomes?

Physical therapists are still looking for the most parsimonious measurements that will predict outcomes for patients.

Are impairments still on the list?

Physical therapy in the Hollywood spotlight

Let's see if the 'bright lights' shine favorably on physical therapy.

Queen Latifah is signing on to play in a Hollywood movie about a physical therapist falling in love.

Queen Latifah has played some authoritative roles: Matron "Mama" Morton in 'Chicago' and Charlene Morton in 'Bringing Down the House'.

She seems likely to bring a strong voice to the role of a physical therapist helping to rehabilitate a basketball player.

The fact that the basketball player is her patient raises some concerns.

Let's hope the 'Cinderella tale' is a serious affair, and not a Tinseltown romp, where Queen Latifah's character considers carefully her professional responsibilities and legal liabilities when involving herself romantically with a patient.

Can we trust Hollywood?

C'mon!

What do you think?

Probably, physical therapists could organize a letter writing campaign to the producers of the new Queen Latifah movie (set to begin in May 2009) that would raise the issue of physical therapists professional responsibility.

Let's shine a bright light of our own in making this movie.

Does anybody want to speculate what this baby is going to look like?

The following industry and trade groups were represented at President Barack Obama's one-day White house forum of changing health care in America.

1. AARP
   
   
2. National Federation of Independent Business
   
   
3. National Federation of Independent Business
   
   
4. Service Employees International Union
   
   
5. American Medical Association
   
   
6. American Hospital Association
   
   
7. Pharmaceutical Research and Manufacturers of America
   
   
8. America's Health Insurance Plans
   

Where was physical therapy?

Where were the physical therapists?

Financial Evaluation and Treatment

How to fix the financial crisis...

...and help private practice physical therapists at the same time.

These recommendations by James K. Galbraith, a scholar at the University of Texas at Austin to the U.S. House of Representatives on February 26, 2009 make a lot of sense to a private practice physical therapist like me...

• a permanent increase in Social Security benefits would help offset the losses that the elderly population, as a group, is suffering on its equity investments and its cash holdings. A thirty percent increase in Social Security benefits would not repair individual losses, but it would keep the elderly out of poverty as a group, and relieve severe difficulties in many individual cases.


• a payroll tax holiday would powerfully ease the financial situation of America's working families, giving them roughly an 8.3 percent pay increase and their employers a comparable reduction in the cost of keeping them on the job. Many mortgages would be paid, and many cars purchased, that otherwise would default or go unsold.


• a reduction in the age of eligibility for Medicare would be a powerful response to the industrial crisis, permitting many older workers who would like to retire but who cannot afford to lose health insurance to do so. This would relieve health burdens from private industry, while not infringing on the employer-insurance systems still in effect for the prime-age workforce. Note that transferring workers from private health care to Medicare in this age bracket has no real economic cost: the same health care is provided to the same people. In fact, the reduction in private insurance claims and bookkeeping constitutes a real saving.

Read Point #4 to get Mr. Galbraith's preface and conclusion - better yet, read his whole speech.

Now, getting all of this done without raising taxes... Impossible?

Motion

Motion.

The new brand statement of physical therapy.

The package is slick, comprehensive (tone?) and stylish.

I like it, but...

Is motion a technique?

Not a decision?

I prefer to think that my special skill is physical therapist decision-making.

Massage therapists and athletic trainers can provide motion techniques.

Still, we need to own a piece of the consumers' mind in this competitive market.

Motion is where the consumer already positions physical therapists.

So, let's run with it.

Do you like it?

Half of Japanese Physical Therapy Practices are Insolvent

Insolvent.

In the red.

More liabilities than assets.

That's where Japanese medical providers (and physical therapists) are financially.

No, it's not due to the current financial crisis.

It's due to Japan's chronic under-spending on health care.

Spending on Health Care	...as a per cent of GDP
Japan	8%
US	16%
Medicare	8%
Note: Medicare pays for half of US health care consumption

The take home message is that US health care providers rely too much on Medicare.

Currently, most US health care providers are solvent.

However, a 21% cut in the Physicians' Fee Schedule on Jan 1, 2010 threatens the largest, quickest-paying revenue stream for many physical therapist private practices.

The Obama administration has affirmed its intent to embrace Electronic Medical Records (EMR) as a means of of cutting costs in the Medicare program.

What does that mean for physical therapists?

Medicare is desperately trying to cut costs before the wave of aging Baby Boomers washes over our heads and drowns us in red ink.

Can physical therapist private practices cut costs faster than Medicare cuts theirs?

Will electronic medical records help physical therapists cut costs?

What do you think?