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.

Insight on PT Board Backing-Off POPTS Enforcement with Commentary on the Private Practice Special Interest Group of CA

As of August 25, 2011 the Board has backed off enforcing their July 2011 interpretation of the Moscone-Knox Act.  As with most good stories, there is more than meets the eye with this one.  A timeline will help clarify the Board's recent position change.

Business arrangements between MD's and PT's that were deemed completely legal by the California Physical Therapy Association in 1990, magically became taboo in 2010 when the California Private Practice Special Interest Group stumbled upon a piece of legislature from 1968 that provided a loop hole to move the anti-POPTS movement forward.  They quickly lobbied to change the code of the California Practice Act and made way for its recent interpretation of the Moscone-Knox Professional Corporation Act which is what AB 783 was intended to amend, making it legal for medical corporations to employ PT's.  AB 783 was subsequently hung up in a state senate subcommittee in June 2011, that effectively killed the bill through 2012.   A victory for the CAPTA.

May 2011, the following letter was sent to the Audit Committee at the California State Capital regarding the actions of the CA PT Board from Mary Hayashi, congresswoman and author of AB 783.  Apparently there might be a few problems with how the Board and the Private Practice Section have been interfacing, how the Board has been adjudicating this process, and if public funds have been used appropriately by the PT Board members.     

July 20, 2011 despite this letter, the Board pushed the button (by the urging of the Private Practice Section) and sent out 155 letters to therapists that had been reported to them by "the public", otherwise known as, competing out-patient therapists.  

August 3, 2011 at their quarterly board meeting, the Physical Therapy Licensing Board (PTBC) had a change of heart.  They heard testimony from the Department of Consumer Affairs, the California Orthopaedic Association, the California Physical Therapy Association, and the California Private Practice Group.  The two former groups pressed the Board to hold off on enforcement of Moscone-Knox Act.  Paul Gaspar and Jim Dagostino, both PT's speaking on behalf of the Private Practice section urged immediate action continue to proceed against POPTS clinics.

August 25, 2011 the Board sent out letters to those POPTS therapists who had submitted compliance plans informing them that they were suspending enforcement of all pending cases until additional legislative time passes to clarify the existing law.  A total reversal of their July position and a clear defeat for the private practice group.  

Why did the Board change course?  Take a look at this timeline and draw your own conclusions.  But I think their actions make it clear that the PT Board realizes there are more than a few holes in their case and want to hold off on getting hammered in court as things stand currently.  Especially if you consider that the Board's big push to enforce the Moscone Knox Act was based on two factors.  One, they had to change the PT practice act that had been in effect for over 20 years to accommodate enforcement procedures by the Board.  Second, the entire basis of their legal argument was based on one or two legal opinions, which don't necessarily have any jurisdiction on the Board or its members.  Specifically:

• Lawyers on the CMA (California Medical Association) have pointed out that this move was based on the opinion paper by Legislative Counsel which isn't binding to the board or its licensees.  
• Unenforceable underground regulation is the term that was used by CMA lawyers to define the CA Boards move to change the practice act in order to enforce their "new" interpretation of Moscone Knox.  This term does not seem to be one that would hold up in court if proved to be true.
• For the entire CMA argument, see my previous blog: CMA Responds to CPTA POPTS Mandates.  Although this letter was dated December 2010, it clearly was a shot across the Board's bow letting them know enforcement of Moscone-Knox, based on an opinion paper, was definitely going to be challenged in court.

• And to put a cherry on top of this story, an email was sent out to orthopedic section members on August 29, 2011 from the CA Private Practice Group Board of Directors stating that due to the actions of Mary Hayashi, the key proponent of AB 783, and her recent inquiry into the PT Boards actions, they want to try to organize a recall of the congresswoman!  Are you kidding me?  
• Shouldn't the private practice section be focusing on clearing themselves of the accusations made in the May 2011 inquiry and focus on the strength of their legal argument (as well as start raising funds for the impending legal battle) instead of going off on yet another emotional rant regarding this issue?   This type of back biting, reactionary politics is unsightly and ineffective at best.  It begs the question: Can the CAPTA afford to waste time, money, and effort on a cause like recalling a political opponent when its Board has misfired this badly over the span of one month?  
• One final point that I hope does not get lost in the minutia of this story.  For all those involved in the POPTS debate both in California and nationally, it should not be overlooked that AB 783 and the surrounding legal debate is serious legislation that has the potential to effect the lives of thousands of therapists not only in California, but the entire United States when you consider how it will be used for precedent in other states.  It should be treated as such by our elected PT representatives.  
• A question for my colleagues.  Why would the private practice section feel the need to go down the recall road (a day after they realized the Board was backing off enforcing their anti-POPTS position) when they successfully defeated this congresswoman and her bill just a few months ago?   Recall her!?  Going in this direction would appear to only muddy the water, making it more difficult to appreciate the good work they just recently accomplished.   
• The Private Practice Section of CA might need to be reminded that they are representing a group of educated professionals in this debate.  Their arguments and actions should be based on fact and merit, and regardless of what tactics are being used on the other side of the isle, conduct themselves with dignity at all times.  If they are deemed to be on the right side of this legal matter, their voice will eventually be heard.   With this in mind, my sincere hope is that they start conducting themselves accordingly.  

CA PT Board Backs Off POPTS Enforcement on California PT's

If you are one those people that thought September 1, 2011 was going to be the end of POPTS (Physician Owned Physical Therapy Service) clinics in California, you probably lost sleep on the eve of the Rapture too.  Allow me to be the one to break it to you, September 1 has as much to do with the end of POPTS as the Rapture did with the end of the world.  
For those of you that have been following this blog, you know that I direct a POPTS clinic and submitted my compliance plan to the board several weeks ago (see blog dated 7/27/11).   Today, I received their response letter and what did it say.....

On August 3, 2011 the Board adopted a motion to suspend enforcement of all pending cases relating to alleged violations of the Moscone Knox Professional Corporations Act.  The Board took this action in order to afford the Legislature time to clarify the existing law.  Accordingly, the Board will take no further action until the Legislature has had an opportunity to take appropriate legislative action to address the issue.

They go on to later state they will continue to monitor the issue, place it on future meeting agendas, but will not be seeking additional compliance plans at this time and no further action is required by individuals working in a POPTS structure.   In other words, it's business as usual..... indefinitely.  Imagine that!?  The home run that the CA Private Practice Section has been so busy patting themselves on the back for over the past 2 months, is really just a long fly ball to right field.

SI Joint Pain, What is it and Who Can Treat it?

If you are suffering from back pain that has not been treated successfully by your health care provider of choice, at your next office visit ask: "Could my SI joint be part of the problem, and do you know how to assess and treat it?"  Get prepared for the twisting of the brow from your average MD as they tell you that is not a common source of back pain, or a stream of babble from your PT or chiropractor about what they can do for you (more on that in a minute).

The truth is, very few people know how to assess this problem, much less treat it.

Finding a qualified health care agent to help you out is like finding a needle in a haystack.  I wish I could post a link to a website or group of qualified treatment professionals that I can comfortably recommend regarding this area, but I haven't found one to date.

Because the waters are murky regarding this topic, I thought I'd help you be a more educated consumer when it comes to this problem.  By asking the right questions and knowing some of the common signs and symptoms, you might be able to help your healthcare professional treat your back/ buttock pain.

Before I get started, it goes without saying that if you are having chronic low back pain or pain in your leg, you should have the requisite tests performed to rule out other pathologies that can cause similar symptoms.  But if you have exhausted the list of possible tests (namely blood tests, MRI, and X-Ray) with your doctor and are still in pain, this discussion might be very helpful.

Here are some facts that might help you decide if you are suffering from this problem and if the person you are seeing is helping you or wasting your time.

• SI joint pain is usually found to cause pain in the buttock area and very often felt on one or both sides of your sacrum "your tailbone."  Depending on how irritated the area is, you may have pain that radiates into your lateral hip and hamstring area, have tightness and pain in the muscles of the buttocks, but rarely does this problem refer pain below the knee level into your calf and foot.  You may experience knee pain on the effected side.
• Sitting on hard surfaces usually is uncomfortable.  You will shift a lot when sitting to find comfort.  Standing will often relieve pain as will walking short to moderate distances.  Arching backwards is usually tight and painful.  Forward bending in most cases will not be limited significantly.
• You may have impaired balance and experience difficulty standing on one leg (the side of your pain) due to weakness at your hip.  In chronic cases that aren't acutely painful, you might simply notice that you sway more on that side compared to the other side.
• Often the pain is described as being deep in the buttock, and is annoying, but not debilitating to the average healthy person.  Due to the mechanical nature of this problem, certain motions of the trunk or leg will usually promote the pain.   The specific motion can vary depending on how the joint is positioned.  

The most difficult task in treating back pain as a health professional is figuring out what is causing the pain.  To be successful in defining back pain you need to work with a health professional that is a skilled problem solver, not a pain chaser.  They must be very good at deductive reasoning and when they are explaining how they are going to help you, should be doing so in a very logical fashion.  If the entire discussion is centered around your pain and how they will address it by working on your soft tissues, BEWARE!  This is a mechanical problem and needs to be addressed as such.  That's not to say that there isn't a time and place for addressing muscle spasms and pain, but at some point, there should be a discussion about the mechanical dysfunction of your Sacrum (tailbone) and your Ilium, i.e. the SI joint.  If this part of the discussion is absent, you can bet they are not highly knowledgable in this area.

In reviewing a couple websites on back pain from The American Academy of Orthopaedic Surgeons and the National Institute of Neurologic Disorders and Stroke, they didn't even mention the SI joint as a possible cause of back pain!  So am I on some crazy tangent regarding back pain or is there a reason why this might be the case.  It depends who you ask.
If you were to ask a group of average family practitioners or even orthopedic surgeons about the SI joint, they will probably blow off the topic, stating that the small amount of motion at the SI joint (9 mm of motion to be exact) is insignificant and, therefore, really couldn't be the source of your pain.  If that were the case, I wouldn't see patients get relief on a daily basis by restoring motion to this joint.  So don't believe that line for a minute.
That being said, if you inquire about the SI joint to a group of doctors called Physiatrists (physical medicine doctors) or skilled orthopedic physical therapists who deal with a lot of patients with lumbar dysfunction, your comment might not get trivialized.  Here's why:

• I once asked a good friend of mine who is an orthopedic MD how much education they got on the SI joint?   He said less than 2 hours of lecture on the topic during medical school.  That might sound surprising, but when you realize the small number of patients that would ever get surgery to this area of the spine, it begins to make sense.  Due to the inherent stability of this joint and lack of intervertebral discs in the normal Sacrum, there isn't much that can be done with a scalpel (except in radical cases).  Since it generally isn't a surgical problem, and is usually addressed with anti-inflammatory and pain medications, it gets blown off as an aside to other back problems.   
• Treating this problem almost always requires some kind of physical medicine; specifically manipulation/ mobilization of the SI joint.  MD's generally don't get this training.  DO's (Doctors of Osteopathy) do get this training, but rarely apply it in their clinical settings, possibly due to the time constraints of an average office visit.  Either way, I believe the lack of treatment capacity by the primary care doctors is another barrier to it being properly diagnosed. 
• Probably the biggest reason SI joint dysfunction doesn't get the press it deserves is that there is not a Gold Standard Test for this problem.  That's right, MRI's and X-Rays are not sensitive to this problem.  I believe this is this reason why it is probably the most underrated back pathology out there.  Don't be fooled when your chiropractor holds up your radiograph and says, "look, your sacrum is off."  If he really believes he can read that from an X-Ray, you should start looking for the door.  
• The closest thing to a gold standard test is a direct injection of the SI joint with a numbing agent.  If you get 80-85% relief, that is considered a positive test and confirms a SI joint problem.  It isn't perfect, but if your doctor goes down this road you at least know he is knocking on the right door (if other pathology has been ruled out).  
• From an office evaluation with your MD or PT, there are a series of tests that can be performed that are called provocation tests because they provoke the pain being caused at the SI joint.    If you get 3 out of 5 positive tests from a select group of these tests, you can also be diagnosed with a SI dysfunction with pretty high reliability.  Which tests are the best is a topic of debate in the literature.  How to treat it is even less defined and is the next major hurdle to getting better.

I will address some of the treatment ideas I use in future blogs.  If you read my previous blog, you are already aware of some of my assessment tests.  If you are a keen observer, you will have noticed that they were not provocation tests and might be thinking isn't that a contradiction to his last point listed above?  This interesting area will also be addressed down the road in future discussions in more detail.  

After reading a few of these SI related blogs you might start thinking there are some ideas out there that haven't made it to main street that could greatly help clarify how to address this tricky dysfunction.  And to that, I would say "I agree whole heartedly!"  Give me a chance, I plan to start working on this issue in the near future.

SI Dysfunction: A Few Easy Diagnostic Tips

For those clinicians that go round and round with how to assess the SI joint, I thought I'd point out a few relationships I came across during my doctoral case study literature review.  My intent here is not to write a literature review, but just plant a few seeds for you to use next time you assess a patient with suspected SI pain.

1. Don't overlook manual muscle test data!  It can tell you a lot more than if a muscle is weak.  Specifically, hip abduction and the L5 myotomal test. You will very often find the side of the up-slip and rotation will have ipsilateral abductor weakness and ipsilateral L5 myotomal weakness.    Take special notice if the weakness is not bilateral.  Take extra notice if you have unilateral weakness in these areas in a fit individual.  After correcting the SI dysfunction, if your treatment is successful, these two tests will often improve immediately upon retesting the same day.
2. Long Sit Test: don't use the traditional ideas discussed in Magee to determine the effectiveness of this test (the studies show it is a poor test based on their definitions).   But when used as a broader "red flag" test, I feel it is an excellent tool.  If the malleoli change in ANY WAY during the supine to sit, don't over think it, just consider the test positive and start seriously suspecting an SI problem.  If the leg length is the same difference in supine and long sit, you have a true difference and start digging around for a heel lift (but I've found this is the minority of people).
3. Last test to consider.  The "Shotgun Test" for adduction strength in a hook-lye position.  If this test is painful or weak (or both) you probably have an SI problem.  Also will need to clear L5-S1 if this is weak.  

These tests are ones that are performed as part of most evaluations, and the Shotgun Test is used as a part of most SI treatments.  But start putting them into your mental assessment calculator, using them as possible SI tells, and you might find your success rate when treating these difficult patients goes up a notch or two.  All questions regarding this topic are welcomed.  

Cost of PT Education

Does anyone think the cost of a PT degree is getting out of control?  I'll admit, the cost of all college education is getting ridiculous, but let's take a look at the cost of PT education.  With the average private graduate program pushing $50K per year and the public schools not far behind, when is the bubble going to be reached where the truly smart individuals start to say, "why would I pay that much to make $65K per year?"   It is a significant problem.  The schools continue to pump out DPT's with the ideals that they are the next greatest thing to the field, and are demanding higher starting salaries as a result.  Clinic owners are short of staff and scared not to meet their demands, offering higher starting salaries, while only modestly increasing their most senior therapists' salaries.  (Which by they way, are the real casualties in this argument.  The new grads are now making close to the experienced therapists.  Is that fair?)
What seems odd is that when I turn away a new grad after stating "this is the best I can offer you," there tends to be another clinic owner out there ready to meet their outrageous demands the following day.  The perfect example was a person I interviewed last year for a vestibular position.  She wanted in excess of $85k per year based on her experience.  But given that she could only see one patient per hour, my math showed she would be making 55% of the gross on her maximum that she could bill (if she were 100% booked), guaranteed regardless of her patient volume.  That didn't seem right and I told her this, stating that a bonus structure could be arranged once her program generated new business outside her own 40 hour a week caseload.  She of course balked, and went to work for a local hospital system.  My question is, what are the bean counters at the hospital doing to create an hourly wage for these people?  At some point, do you not have to figure out how much a person generates vs. what their salary requirements are to make a logical decision?  I sometimes feel I am in the minority when it comes to these business decisions in the PT profession.  And if the majority of clinics are not doing this type of calculus, how are they staying in business?
I fear our profession is in jeopardy of two things.  First, pricing itself out of the market regarding fiscally responsible job offers.  Second, eventually limiting the number of quality applicants in the work field by offering a poor return on investment regarding the cost of their education.  Sure, right now while the overall job market is bleak, there are plenty of people applying to PT programs, but what happens when things turn around?  You don't have to be a genius to figure out a $150-200K loan for  a $65K/ year job is a bad deal.  Will we have bright people coming into the profession down the road if they are smart enough to figure this financing nightmare out?  Can the PT schools figure out how to get the job done of educating our students in a more cost effective manner?  The question needs to be examined.  We certainly can't just keep cranking up the costs year after year and expect things to continue to work out (see the US debt scenario as an example).
Given that reimbursement is only going to continue to decrease in the coming years, the leeway clinics are going to have to hire new grads at these higher rates is only going to shrink.  Would you want to be a new PT in the current market?  How about five years from now?  When are salaries going to have to drop to match the reimbursement of the day?
Unfortunately, I doubt schools are going to get cheaper, much less do I think insurance companies are going to pay us more for our services in the coming years.  It's a pretty picture isn't it!?   But this is a discussion that needs to be addressed.  Why it rarely seems to come up is puzzling to me.  Nothing would make me happier than to have someone convince me things are going in a different direction and that I have it all wrong.  I'll be listening.

ACO's Competing for PPO Business

Historically, ACO (Accountable Care Organization) groups have serviced HMO contracts.  Because of this fact, they have flown under the radar of most PT and MD offices that provide services to PPO patients.  But will that always be the case?  It has yet to be determined, but it is one of the key ideas that will need to be ironed out if the ACO movement is going to have an impact nationally.

• If you were running an ACO, why wouldn't you want PPO business?  The primary reason would center around the capitated pay structure most ACO's were built around and how that impacts how it's physicians are paid.  PPO's with fee-for-service structure don't fit this model easily.
• However, attracting PPO business is important since increasing numbers of national employers are getting away from individual, local HMO products and purchasing national PPO plans for their employees.  This trend has shifted overall insurance coverage away from HMO plans.  
• PPO's are also attractive because they are not regulated by groups like The California Department of Managed Health Care (DMHC), which place significant regulations on ACO business.  PPO service is resultantly much cheaper and easier to provide to patients. 

No one has yet come up with the perfect fix for this HMO/ PPO problem, but given that both providers (ACO groups) and insurers are motivated to find out a solution via the Obama-care initiatives that are coming, it will eventually get worked out.  If a cost effective model can be created (call it whatever you want), the employers who have been getting killed with increasing annual premiums will jump on board quickly if it helps them save money on their bottom line.  And when that happens, the ACO issue might become very real to the general public.

Looking forward, here's where it gets a little scary.  What if you are an independent provider in an area where an ACO aligns itself with all the providers (Medicare, PPO, HMO)?  What if the ACO includes the largest hospital system in your neighborhood?  Can you still compete?  Where are your patients going to come from?  Will your reimbursement rates be anywhere close to theirs?  

For those of you thinking, "Isn't it illegal for hospitals to employ physicians in California?"  Well, there is a business structure called "the foundation model" that makes it all work legally.  The physicians become part of the hospital's foundation, creating an obvious allegiance, but are not considered simple "employees" of the hospital.  The result is you have a group of MD's that become part of that hospital system.  

• The sales pitch from the ACO to the consumer will be that they will be able to provide the best care around because of their signifiant integration of great doctors, the hospital, ancillary services, and great electronic communication.  Patients won't have to fill out their information repeatedly for each doctor they see, since all their information will be shared amongst each of their providers.  This will increase efficiency on both ends and also cut down on repeat tests due to improved communication.  There is a lot of truth to all this.  This is the utopic vision that is driving the EMR revolution.  
• The ACO pitch to the insurer will be that since they can control costs better, they should be able to offer lower rates to their customers.  Initially that may be the case, but eventually the more probable truth of the matter will be that you will have an entity that cannot be overlooked at the negotiating table.  The ACO will have significant leverage to negotiate contracts with PPO providers, which will only make the playing field that much more unbalanced for the independent providers.  Sure there are federal anti-trust laws that help protect against these practices, but they are already in place, and look how fair things are currently!?  The combination of hospital reimbursement rates for Medicare patients and leveraged increases in PPO reimbursement, due to the percentage of the population they are serving, makes sense for the ACO.  But it could very well spell difficult times for those outside the ACO umbrella.  
• Would you want to compete against this group?  I hope for your sake you never will, but I wouldn't bet on it.  Keep an eye on this topic as 2012 unfolds.