Reimbursement is the Key to Beating POPTS

On one of my earliest posts, I responded to a comment regarding reimbursement and would like to follow up and expound on a few of those ideas here.  

What is the most important fight we face today in out-patient PT?

Other than having a legitimate direct access law on the books (which we of course lack in CA), the most important thing is having a reimbursement scheme that is equal and fair. Our current reimbursement rules allow Medicare (as well as other insurances) to provide different rates of reimbursement for the same services provided in a given geographical area. There are generally three tiers of rates:

1.  Out patient clinics owned by PT's 
2.  Out patient clinics owned by MD's (POPTS)
3.  The most egregious offender of the group would be the rates hospitals get for the out patient services they provide. 

For example, most PT practices in SoCal get close to 100% RBRVS (a relative value scale) for Medicare patients due to the expense of doing business here. POPTS in the same area get closer to 120% RBRVS, and hospital out patient PT gets over 200%!  Couple that with the fact that hospital out-patient PT is NOT capped by Medicare as are all other out patient clinics and you have one big money grab.  I used to think that hospitals were taking a hit by seeing those chronically afflicted Medicare patients, but after finding out a few of these facts, I'm more inclined to think that they probably can't open their doors fast enough to get them into their clinics!

So how is it when talking about how to save the Medicare system millions of dollars, this prescient issue is seemingly off the APTA radar???  I've followed the POPTS debate here in California closely over the past year, and this issue wasn't even part of the discussion against POPTS.  It is many times more significant than the concept of self-referral, and I will expand on this idea in a moment.

Unequal reimbursement is one of the most crippling offenses in healthcare; getting paid differently for the exact same services that are being provided simply because (in this case) you submit your bill under a physician group or a hospital system.  This factor is the primary reason the concept of "a level playing field" is currently a joke for independent practitioners trying to compete in the out patient arena.

It has become common to see private insurers make concessions to their largest providers while recouping those lost dollars by reducing their reimbursement to other smaller clinics in their networks.  In the PT world, the closest thing that exists to having leverage with an insurance company is to have a network of clinics.  We see it with the large companies like Physiotherapy and Associates and HealthSouth to name two.  The other option is to join a network like PTPN that tries to bundle independent clinics in an effort to negotiate better rates on the same basis.  The idea being that by having hundreds of clinics (that serve thousands of patients), you might be able to negotiate a better contract than if done alone as a single clinic.  Sometimes it works, and sometimes it doesn't, but at least you have a seat at the table.  Single entity providers have to take what they can get when trying to become a preferred provider for any of the large insurance companies.  If you don't like their rates, don't join, it's that simple.

But the leverage that is applied within the boundaries of PT corporations is minuscule in comparison to the leverage ACO's, hospitals, and large physician groups can place on an insurer.  Since they are generally the point of access for most of their patients, loosing their services would effect, in some cases, hundreds of thousands of lives, and insurance companies often can't afford the backlash from their participants.  Therefore, they usually are forced to pay these groups higher rates for their services.  When a PT entity is involved in that negotiation (as part of an ACO or POPTS), they usually get a better deal than non-POPTS or non-hospital based clinics would receive.  This fact is what makes offering PT services attractive to these groups.

Where is the APTA on this argument? Your guess is as good as mine.  However, the way to beat this phenomena might be counter intuitive.  PT's, as with most health professionals, are always calling for more reimbursement and more dollars from the federal budget.  But isn't Medicare going broke?   Wouldn't this be the easiest band wagon to start of all time regarding PT on Capital Hill?

PT WANTS LESS REIMBURSEMENT TO SAVE MEDICARE.  

And when I say less, I mean, do away with the 120% and 200% RBRVS amounts being paid to hospitals and POPTS.  Put the care back in the hands of private PT's and let's save the system millions while providing better care.  The data supports this idea.  The pressure would have to come from Medicare via the voters.  No small task given that medical and hospital lobbies would try to crucify any such cuts.   But if it were put into place, can you see, given the economic state of the country, that the house of cards could start coming down quickly?

If the battle cry "Equal reimbursement for all!" started to resonate, PT's might be able to knock the financial carrot right off the stick!  The profit margins that attract our services to hospitals and POPTS would evaporate and maybe they would get out of the game.  The insurers would love it for obvious reasons, and wouldn't the public as well?

It would be difficult to keep going with these lower rates in the short term, but the out-patient PT centers that are already in existence have a distinct advantage.  They have already figured out ways to succeed with the current rates in place.  If the plan worked, eventually as the POPTS and hospital based centers got out of the game (due to lack of profitability), there would be more patients to go around and it would start to get easier via increased patient volume for the remaining clinics.  PT would be more than half way to controlling its own destiny.

The second phase of this process would be to continue working on tightening legislation on the employment of physical therapists, similar to what has been achieved in Delaware and South Carolina, to permanently change the landscape of PT in the United States.  This would set the table for the last transition of this idea.  For those individuals asking themselves, "aren't we unsuccessfully trying to do that right now?"  I would respond, there would be a major difference going forward at that point.  If the money wasn't there, the amount of opposition should be significantly less from the American Medical Association and hospital associations.  Why would they fight for something that is loosing them money?  (Because they want to continue to strive to provide better patient care.....right!)

Continuing with that thought, as PT owned clinics started providing the majority of services in the country, a clear crossroads would surface:  How to charge for PT services?  At that critical point in time, there might be room to jump off the preferred provider merry-go-round.  Physical therapy would have the opportunity to start thinking like dentists and a payer model that is more fee for service, in its truest sense:  set a fee, allow insurance to pay out of network rates, and let the patient make up the difference out of pocket.  Stop making exorbitant write offs, via low-ball preferred provider contracts, and start collecting for what should have been all along.

The biggest obstacle at that point would be PT's themselves.  Because if it ever got to that point, they'd then have to compete with each other based on skill and outcomes.  Something many PT's would fear, similar to what the teacher's unions run into when they start trying to reward good teachers and weed out weak ones.  Additionally, there would be those providers that would never want to stop participating with insurance companies for their low, guaranteed rates due to the members that come along with it.  This would only complicate the horizon.  But if only a handful of clinics participated in these networks due to their low reimbursement, then the net effect of these weak few, would be marginal.  The idea would be to start changing the public's perception of what is normal and customary for PT.

If a low insurance and moderate patient contribution was PT's primary private payer mix (similar to how out of network dentists handle their business), then setting the price for services would become a careful balance of a PT's skills, the market for a given region, and ultimately patient choice.  Isn't that what a free market is all about?  People would have to decide as to whether or not your services validated your fees.

Just think about your dentist.  Why do you keep going there, or why have you left recently?  Wouldn't you like to have a chance at putting yourself in front of the public in a similar fashion?  I would and you should too.  But if the idea scares you, you should take a good look in the mirror and start working on your skills.  Autonomy doesn't come cheap.  And if physical therapists continue to ask for it, they need to be prepared to ready themselves for the transition.

California SB 543 is Signed Into Law

It's official.  Good ol' Gov. Jerry Brown couldn't sign this bill fast enough to clear off some space on his desk.  In a message from the California Physical Therapy Association:

On Monday October 3, Governor Jerry Brown signed into law SB 543 a bill that prevents the Physical Therapy Board of California from enforcing the law pertaining to physical therapists that are employed by medical, chiropractic and podiatric corporations.

The impact: POPTS will continue in CA without flinching until 2013.  Then a sunset provision takes effect and this bill will have to be re-heard.   Unless Medicare breaks out some sweeping changes in the federal law, this issue (as far as the PT Board is concerned) is now very much a non issue.

CrossFit: a True Gift to Physical Therapy

If any of you have come across the newest fitness craze, CrossFit, you know that this is hyped as the next best thing in personal training.  I was introduced to this program at a party a few months ago where I was able to talk to an owner of 2 such facilities.  He let me know that these programs are run in his gyms at a cost of roughly $135/ month per client.  Their programs emphasize small group workouts with personal trainers that specialize in high intensity, compound movement exercises that get your heart rate up quickly and fatigue you in a 20-30 minute session.  Appropriate warm up is provided before the workout.  He emphasized that their trainers carefully watch form and provide close supervision at all times.  It all sounded like stuff I'd heard before and I didn't think much of it, until I saw the CrossFit World Championships last weekend on ESPN2.  After witnessing that, I became much more interested.  To bring you up to speed, here's what it all seems to be about:

• Crossfit World Championships show young, incredible athletes going through a series of activities that would put the average person in bed on Advil and ice for a week.  It is a newer, hipper version of the Worlds Strongest Man contests that you can usually catch at 2 am on ESPN.  Check out this link to get a feel for it. http://games.crossfit.com/    I had such a montage of emotions watching this event, I had to write this blog.  A combination of laughing, wincing, analyzing body mechanics, and watching in amazement at what the athletes could tolerate and overcome.  Certainly worth tuning in if you get the chance.  I was amazed I didn't witness a significant shoulder or knee injury during the finals due to the brutality of the event activities.  
• CrossFit Centers regularly include exercises in their training workouts that include squats, box jumps, lifting objects such as tires, various types of push-ups, inverted push-ups, lunges, medicine ball activities, and most accepted types of plyometric exercises for the upper and lower extremities to name a few.  
• The workouts are changed almost daily, to help confuse the muscles and get better strength results.  Similar to the P90X philosophy.  The list of exercise activities I made above is only a small slice of what you would see at one of these facilities.  
• An entire video library of examples can be seen at: http://www.crossfit.com/cf-info/excercise.html#Exer.   I added one here so you can get a feel for one of their milder exercises.

 This quote was taken directly from their website:

The CrossFit program is designed for universal scalability making it the perfect application for any committed individual regardless of experience. We’ve used our same routines for elderly individuals with heart disease and cage fighters one month out from televised bouts. We scale load and intensity; we don’t change programs.

Isn't that great, the same routines for our elderly and our cage fighters.  I don't care how you scale it down, certain exercises are not appropriate for the elderly.  The above example, the full squat, while great on a young healthy knee, puts incredible compressive force on the knee cap as well as the knee joint surfaces between the thigh and leg bones of the knee.  This video would be the perfect way to tear a meniscus or irritate a mildly arthritic knee.  The real question you should ask yourself before trying an exercise like this is, why do I need to do this exercise?  If you are a furniture mover and need to bend down fully many times a day, you might have a reason.  But if you are the average 9 to 5'er that sits at a desk all day, you really don't need to punish your knee joint like this to strengthen your hips and thigh muscles.  If you don't believe me, go see a physical therapist and they will show you how to save your knees while doing squats.  Maybe a good topic to discuss in a future blog.

After looking at a few of the exercises on the CrossFit website, I thought I'd pull out an example of an exercise that really has no place in an exercise regimen when exercising the elderly (or average weekend warriors for that matter).   An example would be the box jump, which is an activity where an individual either jumps down from a box, or up onto a box repeatedly.  The faster the transition from the jump down to the jump back up, the better.  This family of training techniques are referred to as plyometrics and were originated in The Soviet Union for olympic athletes in the 1970's to improve speed and power.    A video is worth a thousand words, to see the CrossFit version of these activities, see below:

Even from the most modest heights this exercise could be a nightmare for an osteoporotic grandmother wanting to "get in shape" given the increased risk of compression fracture in the spine, hip fracture, or joint damage on arthritic lower extremity joints.   If a physical therapist were to prescribe these exercises to a Medicare patient and they subsequently broke a bone, at best you'd never see another patient from the referral source, and at worst you'd be sued by the patient.  I would hope CrossFit trainers receive training that would make them aware of some of these contraindications, but I have no way to verify that, and I probably wouldn't bet on it.  

For those 40-50 year olds wanting to give these workouts a try, I would advise you to remember a few things.

• Most of the athletes you see doing these exercises are in the prime of their lives (20 to mid-30 somethings).  Their joints and discs are in very different places than someone 20 years older.  What is a challenging workout for them, could be pathological to an older, less fit individual.
• Plyometrics were designed originally for olympic athletes.  These are individuals that are professional athletes.  A tenth of a second in a sprint event, or an extra inch or two of vertical jump can be the difference between being on a medal podium or watching from the bleachers.  For them, these exercises are required to excel in their respective sports.  Therefore, the risks of plyometric exercises are an acceptable part of their training regimens.
• Risk you ask?  These exercises have a much higher risk/ reward ratio than doing traditional exercises on weight machines or with controlled free weights or bands.  Simply put, plyometrics do have the potential to provide great power and strength increases for an individual.   But they are also some of the most risky activities to include in a work out program due to their explosive nature.  They put extremely high loads on tendons and muscles, which greatly increases the chance of muscle/ tendon strains or worse, rupture.  And that's only the contractile tissues!   They also place incredible loads on passive structures like ligaments, bones, fascia, cartilage, and discs to name a few.  These activities can easily land you in an orthopedist's office, even with the best of form.  
• Pro and college teams usually only include these activities in the off season workouts due to the increased time muscles need to recuperate from these workouts.  Performing plyometrics during the regular season would overload muscles and tendons and put athletes at increased risk for injury.  That should hopefully get your attention as to how serious these exercises are, especially if you are reading this in the capacity of a weekend warrior.  
• If you are not a relatively fit individual, be very cautious entering into one of these programs.  Make sure you have excellent instruction, know the risks involved, ask yourself if you need to take these risks, and know your medical history.  If you have any kind of joint, disc, or bone density pathology, check with your physician or physical therapist before you proceed.  
• Exercise is needed in most individuals lives to be happy and healthy individuals.  Fortunately, to gain the health benefits from resistive exercises, you are not required to perform exotic exercises that involve jumping off boxes or lifting up tires.  Moderate resistance exercises performed 3 x week is adequate to gain strength in a 4-6 week period.  Moderate intensity resistive exercise has also been shown to improve bone density in many studies.  Use common sense when choosing your workout plan.  

A wise physician once told one of my patients "All things physical, are not therapy."  Keep that in mind as you weigh your exercise choices.  Be smart and remember, exercise is supposed to help you stay healthy, not hurt you!

How Can PT's Get on The Same Page Clinically?

I can remember being in PT school during the late 90's and talking about an article written in the mid 90's by an under cover reporter who went to 10 PT clinics and got 10 different diagnosis for their back pain.  It was not a flattering article for the PT profession!  My classmates and myself sat around and said "wow, glad we are going to be part of changing all that inconsistency."  We figured with our classes in differential diagnosis and up to date orthopedics, this would certainly change.  Not to mention, we were going to have the brand new "Guide to Physical Therapy Practice" to lean on, we were all set.

• Well, I've had two encounters in the past week that makes me think we still have a very long way to go.  The first case was a lady that came to my clinic from a familiar referral source requesting this patient see a McKenzie Trained therapist.  Although I am not McKenzie certified (and I explained this to both the MD office and the patient before seeing her) I am very familiar with the concepts and know how to treat a patient with discogenic pain with radicular symptoms.  I find out after evaluating the patient she spent 4 weeks at another PT clinic that didn't give her one extension exercise or trial traction with her during that time.  Her presentation was textbook disc, unilateral pain down lateral calf and foot.  Increased pain with flexion, relief with extension.  Numbness and tingling, worse with sitting, better in standing.  And so on, and so on.  I mean, you could have used her for a licensure board question.  So how is it that there are clinics out there that have no idea about standards of care for a disc injury?  This was not some tricky, fringe diagnosis, or even something that required a series of special tests.  This was a disc injury, arguably the most diagnosed back problem in the United States.  You can easily argue that the clinic should be categorized as incompetent.  When I encounter these stories I don't jump up and down thanking the PT gods that I gained a new patient, I get frustrated that I have to associate myself with this level of therapist that holds the same license I do.    
• The second case I happened across was on the sidelines of my daughter's soccer game.  One of my fellow parents had an ankle splint on.  I asked him what he did, and he mentioned he fractured his distal fibula 4 months ago at work and was dealing with a non-union injury.  He was trying to avoid surgery, and had been receiving PT over the past 2 MONTHS!  He also mentioned this was a work comp injury.  My question is this: what the heck are you doing with a fractured ankle for 2 months in a PT clinic?  His range seemed fine, so last time I checked it needed rest, protection from a boot and possibly a bone stimulator.  The boot was removed after 4 weeks, no bone stimulator, and the PT clinic kept treating him with band exercises, stretches, and ice and electrical stimulation.  As a reminder, I work for one of the "substandard quality of care POPTS" and this person was being seen by a PT working at a PT owned and operated clinic.  That obviously has everything to do with quality of care.... but I digress.
• Anyway, I told the guy that non-union fractures don't need exercise they need protection, a bone stimulator trial, and making sure his calcium/ vitamin D intake was at recommended levels (which it wasn't since he didn't like to drink milk).  He agreed, and was wondering why the clinic kept doing the same things over the past 2 months despite his ankle not getting better.  I told him it really wasn't a PT issue until that bone starts healing.  Did the clinic need the business that badly to max out this guy's work comp benefit?  Or is it simply another case of negligence?  The nice second part of the story will be that when it comes time to gait train this guy and work on his significant leg atrophy, he will have used up his 24 visits the state provides and be left out of the clinic during the time he needs this benefit.  
• In both cases, I walked away feeling queezy about our profession.  I think it is time we start looking for ways to guarantee that our PT work force is up to date and weed out the dead wood.  Yes, that might mean we have to take board exams on regular intervals similar to what MD's do.  We are trying to talk about ourselves as doctors right?  Well, maybe it is time we do a little more from within our profession to improve the care we are providing as a whole which would only strengthen our argument for direct access.  When I hear these stories, I wonder if my brethren are really qualified for direct access responsibilities?  Think about the PT's in your clinic, would you trust them to treat your mother as a primary care provider?  How about PT's you encountered during your clinical education or from your PT program?  The number I would trust are counted on one hand, maybe two.

Anyone else out there seeing these types of problems?  If so, I would like to hear the ideas and possible solutions to this significant problem you have come across.  It's a discussion that obviously warrants more attention from the PT profession.  

And The CA POPTS Winner By TKO is.........

The California Medical Association (CMA) is on the brink of dealing the California PT private practice effort to stop POPTS (physician owned physical therapy service) a deathblow.  CMA's funding and support of senate president Darrell Steinberg has landed them a piece of legislature (SB 543) on the desk of Governor Jerry Brown's desk that will prevent the PT Board of California from being able to take action against the PT's that are working in Medical, Chiropractic, and Podiatric Corporations.  It easily passed through the senate with a vote of 32-5 earlier today.
If signed into law, it will make the Board's interpretation of the Moscone Knox Act irrelevant.  Even though the Board feels physical therapists are working illegally for these corporations, they may very well find themselves powerless to do anything about it.
For all the fanfare the Private Practice Special Interest Group of California raised for their stalling of AB 783 (which would have flatly made these medical corporations legal by all accounts in California), they ultimately lost the fight by knockout to SB 543.  The submission of a bill that voids the Board's authority on this entire issue was brutally clever, and obviously caught the PT lobbying group with their guard down.  If passed, the anti-POPTS issue becomes about as dead as disco over night.
I have mixed emotions about this matter.  For one, I have gained a healthy respect for the power of the CMA in this state and their ability not to simply support and pass a bill, but to fund and pass an entire idea.  They wanted POPTS to stay, and worked on multiple pieces of legislation and multiple congressman/ women to make it happen.
With regard to the PT effort, maybe it is time the PT world starts admitting that going head to head with the AMA is not a great solution to many of these issues.  I'm seeing a prize fight that offers up a Heavy Weight vs. a Middle Weight.  Do PT's think they can out maneuver the CMA/ AMA?  Out spend them?  Do they think PT's have more influence in the healthcare debate then doctors do?  We might be able to slip in a jab here and there, but the probability of a knockout punch on any of the major issues of direct access, POPTS, fair representation in the ACO discussion, and equal reimbursement amongst providers is slim at best.  
If the PT leadership cannot change its tact slightly to work towards thoughtful and meaningful compromise, as other states have on some of these issues, I fear PT's are doomed to see very little change in the coming years in the state of California, and maybe even see things get worse.   By drawing lines in the sand and taking an all or nothing stance on issues such as direct access and POPTS we ultimately leave ourselves open to stark defeat.  This same flavor of politics is being played out in our nation's capital as we speak, and look how effective that has been over the past couple years!?
Hopefully this significant defeat will serve as a beacon that it is time to re-think the physical therapy position and really focus on the most important issue on the table, REIMBURSEMENT.  By doing so, PT's can make sure they don't repeat their POPTS battle mistakes when entering the political ring for that title fight.  

SI Pain Subjective Feedback Key

Are any of you clinicians who might be wondering what historical feedback can help cue you into a patient with SI pain?  The good news is you only have to ask one question (that has any real relevance statistically).  


Michaelsen, Pauza, McLarty, and Bogduk showed that most historical data are not useful for diagnosing SI joint dysfunction with the exception of patients stating “relief with standing” which had a likelihood ratio of 3.9. This means that people who report reduced pain at the lower back with standing are 3.9 times more likely to have a SI joint dysfunction.  The Confidence Interval (CI) was not reported.  


So if you are thinking of altering your back evaluation forms to help screen for SI dysfunction, make sure this question is included.  

The Answer: Why PT Board CA Backs-Off

Based on this August 30, 2011 report from NBC LA, I think I understand why the PT Board of CA changed its tune so quickly.

The California Medical Association and its legislative allies in Sacramento have triggered a state audit of a regulatory agency that, they say, is too cozy with independent practitioners in the lucrative physical therapy trade.

On April 23, the Assembly's Joint Legislative Audit Committee voted 12-2 in favor of a five-month examination of the Physical Therapy Board of California, the watchdog agency responsible for overseeing "PT" clinics and practitioners across the state.

To see the entire article, click on link below.

http://www.nbclosangeles.com/news/politics/Physical-Therapy-Group-Audited-by-State-128717163.html

You can only guess if this audit had anything to do with slowing down the Board on enforcing action against POPTS clinics, but my guess is this is what put the brakes on things.  Of course, the whining about this matter couldn't be louder from the PT world as noted by most of the comments on this story.  For a detailed build up to this point, please read my previous blog dated 8/31/11 on this topic.