The choices people make and why they make them captivates me.  For a couple of days, I've been thinking about how to convey, in a kind way, something I read.  The mom's choices and actions didn't bother me - she's really doing what any good mom would do.  What bothered me, "I would call physical therapy places... they either didn't have the equipment, or the manpower or they didn't take my insurance." So, the daughter is now 2 years or so post spinal cord injury and this is what she states about the recovery center her family owns, "There's no other type of therapy place that offers hope like we do. I get to work with them and we get to reach our goals together," says Amanda.

My curiosity always takes me through some cognitive journey.  I wondered what was available in Florida for people with a spinal cord injury.  The first thing that came into my head was the Miami Project.  They have made a huge dent in understanding spinal cord injury.  I didn't easily see information on becoming a patient, but with a bit more searching, I found the University of Miami does have a Department of Rehabilitation.  Amanda's mom didn't indicate anything that occurred in the initial stages of rehabilitation or where rehabilitation occurred.  Somehow she found Project Walk.  Project Walk hinges its whole entity on the Dardzinski Method and the Five Phases of Recovery.  Interestingly, as I tried to learn more about the supporting evidence of the theory, I was led to a neat paper written by Professor Mary Galea who shared on page 8 of that document her thoughts on Project Walk. Galea also included a reference on intense exercise and spinal cord injury by ET Harness. 

Stories sell.  All the stories seem to revolve around hope.  The clients are more than willing to pay $100 or more an hour out of pocket for sessions 3 times a week.  I didn't see a single claim of actually walking independently again.  I wonder how the physical therapy sessions ended?  I mean, the mom could have continued paying for services out of pocket... the physical therapist could have continued to work with the daughter providing intense exercise.

If a patient believes the relationship with us is coming to an end too abruptly and would like more services, how do we handle the whole end of insurance benefits for the condition?  Are we a factor that propels people to pay for unproven methods and potential false hope?  Is it wrong to continue a working relationship if deep down we believe no substantial progress will occur?  Is it wrong to attempt to help a patient to learn to accept and cope?  Why do some patients view this as giving up?

~Selena

Don’t forget that EIM’s 30 Second Elevator Pitches on why physical therapy is the Best First ChoiceTM in musculoskeletal care are due on November 30th.

Top prize is $1000, second is $500, and third is $250!
Check out Elevator Pitch info on Wikipedia or see last year’s winners… first, second, and third places.

Video and Audio submissions are taken via email @ elevatorpitch@evidenceinmotion.com

Rules:
• MUST answer “Why Physical Therapy is the Best First ChoiceTM for musculoskeletal care?”
• 25-30 Seconds (no longer, no shorter)
• Individuals Only
• Must be a PT Student or practicing PT
• No Entry Fee
• Submit via email @ ElevatorPitch@EvidenceInMotion.com
• Include name, email address, school or place of work, phone number, and age with submission
• Must be in the form of video or audio files
• Submissions are due no later than 11:59pm, November 30, 2009
• Winners will be announced on Facebook, My PT Space, and YouTube on December 15, 2009 at 4pm
• First place will receive $1000, second gets $500, & third gets $250 (winners contacted via phone & email)
• All submissions and their content will become the property of Evidence In Motion, LLC
• Email ElevatorPitch@EvidenceInMotion.com with questions and visit EIM’s website for more info

I recently had a sandwich prepared with white wheat bread.  It is essentially whole wheat bread “disguised” as traditional white bread.  The intent I guess is to provide for me a healthier option without me really knowing it.  Not sure this qualifies as innovation or marketing.

The same is true of for IBM’s decision as reported in Oct 29th WSJ article regarding dropping co-pays for primary care visits.  IBM is one of largest employers in the US and spends about $1.3 Billion on healthcare.  Because they are self-insured, they carefully watch every dollar spent in the medical system.  It is their belief that they can save significant money by incentivizing folks to use primary care physicians by eliminating co-pays so they can get earlier diagnoses that can save more expensive visits to ER’s and specialists.  I will let you decide whether this is innovation or marketing.

Contrast this to the incentive system in Massachusetts “global payment” system which creates tremendous incentives to render as little care as possible.  If your care costs less than an annual allotment, then they (medical providers or a hospital) keep the unused amount.  While the pendulum on too much care in the US is undeniable, its compete counter of too little is equally as bad.

My post last week on “bundling” creates a financial incentive for a patient to choose a provider within a set system-the patient essentially gets a cash rebate under that demonstration project (side note:  this worked real well in the auto industry).

I seriously doubt IBM will save money under their initiative since primary care docs are in a shortage and patients will simply get frustrated and pay the co-pay to see a specialist. All IBM needs to do is look at Massachusetts primary care waiting in their system which is 2–3x national average!However, I do think that all of these marketing tactics can be replaced by real innovation- which would take into account best current evidence, utilization data analysis, and some element of financial incentives to drive patient choices.

Here is a start of a list for PT that tries to couple this concept:

1. Pay patients $20 rebate for seeing a PT for musculoskeletal cervical or lumbar pain.  They first follow a simple online or iphone/blackberry app that largely eliminates the major red flags that would guide them to a more appropriate provider.  The $20 would be well spent.  Savings on imaging and drugs would be astronomical.

2. Any service done thru physician self-referral has an additional $200 co-pay.  Routine lab and X-ray would not be included.

3. Patients have zero co-pay if they pro-actively pick their personal family physical therapist who is board certified or resident trained and who actively participates in 3^rd party outcomes.  Their personal PT also agrees to answer emails/texts/phone calls about routine musculoskeletal complaints and provide a free fall balance screen once the patient turns 60.

Combining evidence and incentives vs. marketing. That just might get us to some real answers.

Thoughts?

larry@physicaltherapist.com

What to do for neck and arm pain that started within the last 30 days?  Drum roll... which will it be the a) just wait and see what happens, b) the semi-hard collar (Cerviflex S, Bauerfeind)  which has 6 sizes to snuggly fit necks of all sizes, or c) physical therapy?  The winner is.... the Cerviflex S semi-hard collar!

In this century of effectiveness and effectiveness studies.... What a spectacular day for people who have cervical radiculopathy - just strap on a snug fitting semi-soft neck collar and life will be fabulous within 6 weeks!

I was fearful of these types of studies because the devil is in the details and as a whole, we are lazy.  Which is more realistic?  Read an abstract and believe the conclusion OR read the full study and reflect and think?  I'm betting most will read the abstract and believe the conclusion.

I liked that the subjects seemed to be a homogeneous group.  I like the fact that the same collar was consistently used.  I don't like not knowing psychosocial factors.  I really don't like the description of what physical therapy intervention was provided.  "Physiotherapy with a focus on mobilising and stabilising the cervical spine was given twice a week for six weeks, by certified physiotherapists who participated in the study. The standardised sessions were "hands off" and consisted of graded activity exercises to strengthen the superficial and deep neck muscles."  

Current literature indicates that manual intervention and exercise are key components for a successful outcome with various types of patient complaints.  Standardized sessions that are hands off do not meet the requirements of evidence.  The design of the study capturing the interventions provided by physical therapists really wasn't up to speed on the existing evidence on how physical therapists treat patients with cervical radiculopathy. 

It's a sad, sad day when the physical therapist involved in the design of the physical therapy intervention wing of a study didn't incorporate evidence into the treatment protocol.  I really have a problem with the design of the standardized physical therapy sessions!  Where was the evidence for the protocol?

So, the big question... which payer will see the abstract... which payer will deny payment for physical therapy services because physical therapy services are not cost effective and a neck collar will "effectively" take care of the patient's cervical radiculopathy?

~Selena

Larry gave me the most excellent idea.  Bundling the Cost of Care got me thinking about the future.

Last night was my initiation as a physical therapist gone negotiator!  I was 100% successful in acquiring THE largest pieces of chocolate candy (or whatever choice I wanted) out of the bucket!  In some cases, the whole bucket of candy was just handed to me!  (I was polite every time and smiled and said, "thank you.")

I am so ready to be at the service of any physical therapist that has to negotiate with some large hospital system for the payment of physical therapy services provided by an independent physical therapist.  Trust me, as your negotiator, I know how to walk quietly and carry a big stick.  Your company will survive this change; you and your family will survive this change.  I know you have to put food on the table and eat.  Call me and make my day... I am so ready to negotiate for you!

Physical therapists in independent practice really can't negotiate AND treat patients.  Consumers really should have quick access to physical therapists no matter where they practice; consumers should have the freedom to choose their physical therapist.  Seriously now... Larry didn't get any responses.  My humor won't solve the issue.  Really though, will the next growing field in the future be physical therapist gone negotiator? 

~Selena

Is an orthopaedic surgeon a "qualified health care provider" with regard to providing physical therapy services?

According to the Kentucky Supreme Court, yes, an orthopaedic surgeon can provide physical therapy services and is a qualified health care provider. What can I say? Over the last 6 years, the case went through the whole darn court system and a final ruling occurred in the Kentucky Supreme Court. The result... since section (1) proviso allows orthopaedic surgeons the authorization to provide physical therapy services, but since section (3) disallows the orthopaedic surgeon from referring to the services as physical therapy either directly or indirectly - an "absurd" situation is created. Apparently, the General Assembly wanted the statute to be considered as a whole and for all pieces within the statute to be relevant. The General Assembly would not want an absurd statute.  It all comes down to it being absurd that an orthopaedic surgeon can't offer and bill for physical therapy services provided by an athletic trainer using CPT 97001 and 97002.

Personally, I find it not only absurd but also illogical that an orthopaedic surgeon would be allowed to provide physical therapy services without a physical therapist providing services.

If we put some practicality into the situation... first of all, an orthopaedic surgeon is not in the clinic every day of the week.  The "surgeon" will have 1 or 2 days (or more) per week in an operating room, right?  So, when the surgeon is operating, the surgeon really can't be supervising any physical therapy services that might be concurrently provided within the surgeon's clinic right?  We'll forget about that reality for a minute.  When the surgeon IS in the clinic, what is the surgeon doing?  If we guesstimate the surgeon has an 8 hour working day, then that means the surgeon has basically 480 minutes.  Of that 480 minutes, the surgeon will probably have 20% downtime - waiting for radiographs or MRI results or conversing with other colleagues or documenting... that leaves 364 patient contact minutes.  Approximating an average of 10 minutes of surgeon-to-patient contact, a full day would be approximately 36.4 patients.  In that full day of surgeon-to-patient contact, does it seem reasonable that a surgeon would have the time to adequately address and supervise the provision of physical therapy services being provided by an athletic trainer?

Until third party payers eliminate referral for profit situations, the Kentucky Supreme Court opinion just may create ripples across the nation substantiating the legal right for physicians to provide physical therapy services.  Until consumers care enough to compare before they seek a physical therapist for their condition, the situation won't change.

Is it possible for physical therapists to create a viral message?  Physical therapy isn't physical therapy without a physical therapist. Put the PT in physical therapy. 

What are your thoughts?

~Selena

Larry Benz at the 2010 International Private Practice Business Summit

Hello!

I would like to personally invite you to the 2010 International Private Practice Business Summit on January 22-24, 2010.  The Summit is a 3-day business meeting for private physical therapy practice owners. There will be more than a dozen experts presenting on topics related to the business of physical therapy and strategies for creating high performing and prosperous world-class clinics.  This Summit will motivate, inspire and teach everything you need to know to transform your clinic into a top-notch, competitive, enjoyable business. 

I will be presenting “Clinical Excellence Begins with World Class Customer Service”  on January 22^nd.  While physical therapy clinics are stressing their clinical expertise, practices with unprecedented focus on the customer experience and service excellence are gaining market share, “buzz”, and loyal repeat patients trumpeting their competition.  I will focus on the ultimate outcome of a physical therapy experience-an emotionally engaged, enthusiastic ambassador who has been impacted for life from treatment at your physical therapy clinic.   This session will give you the tools to deliver and sustain “the best” customer service experience for your patients.

Registration opens today, October 28.  If you register prior to November 19 you will receive an early decision maker discount.  Click here to register.  

Hope to see you there!

Larry

Health Care Reform... 21.5% reduction in payments to providers... possible shifting of reimbursement to favor primary care physicians... possible reducing payments to physical therapists to increase payments to cardiologists and oncologists. 

It seems to me to really resolve any problem there are always various considerations.  In the case of health care reform... there are at least 3 entities to consider.  1)  Medicare - its processes:  the inefficiencies, strengths and weaknesses  2)  Providers -  their processes:  how clinical decisions are made, the risk/benefit of the decisions and 3) Patients - their behaviors:  when they seek services, their responsibility in taking care of themselves, when they make poor choices.

I am so ready for a primal scream when I see something like the above and then read the details.  The government can't have it both ways... their audits in clinics capturing money paid inappropriately due to lack of "medical necessity" basically based on review of records yet the allowance of $60 billion in fraud to people who easily scam Medicare!  Medicare is paying for that fraud annually (of course, these are just the ones who got caught)!  In all honesty, providers should not take such a hit in reimbursement yet.  Medicare should have its own work cut out to clean house and ensure someone really needs an electric wheelchair or an electric prosthesis.  Amazing to hear Medicare will easily pay for 2 lower extremity prostheses and an electric upper extremity prosthesis on the SAME person!  Now come on, how many people 65 and older do you know who are THAT bionic?? 

I have no clue how powered mobility devices are billed.  I do know if a patient received any kind of prosthesis concurrently there would be claims sent for physical therapy and maybe occupational therapy.  I would think a darn computer system could process durable medical equipment claims for defined durable medical equipment items 20-30 days after receiving the claim and only pay if inpatient services or outpatient physical therapy services were provided within the same time frame.  I'd highly doubt anyone receiving a prosthesis would know how to function and be safe without some level of education and training.  Even if the prosthesis was a replacement, Medicare can just make a rule that rehabilitation services are required. 

If 10-12% of claims are for physical therapy services, does it seem strange to anyone else that OIG will be focusing on outpatient physical therapy services provided by independent physical therapists?  I highly doubt that physical therapists in independent practice are exploiting the Medicare system intentionally or unintentionally at the magnitude the guy in the video was.

~Selena

In yet another shotgun approach to saving healthcare, USA Today ran a front page article “Can ‘bundled’ payments help slash health costs”.

It detailed a 3 year medicare demonstration project in Tulsa, Ok which started this past May whereby CMS will pay a single payment for all the hospital and doctor care for heart and joint procedures rather than the traditional separate fees for providers and facilities.  A picture of a patient receiving PT at one of the “approved” PT centers participating in the “bundling” program is shown.  The article points out pluses and minuses of this concept.

While no doubt a bundled system for certain items in medical care makes great sense and we have frequently documented in this blog the problem of “overtreatment” and the article aptly points out the collective efforts to eliminate waste in the surgical process (e.g. too many surgical drapes) as well as care that is not based on good evidence. However, the notion of transferring administration of care and payments to a hospital makes about as much sense as having the vehicle license bureau co-exist as a dayspa. 

It is one thing for a hospital system to be forced with DRG’s and other bundled payments by a payor but that is significantly different than putting the hospital in a system to negotiate with implant companies, contract with the most efficient providers, and then transact claims and payments to providers.  Managing cost and managing care are as different as selling license plates and performing a facial.  At the end of the day, you would end up with a significant conflict of interest-all services would be rendered at a hospital which is the most costly cog in the system or there would be the “limbo” contracting of providers and services for rates probably half of what medicare currently reimburses.  The article aptly points this out to a certain extent by mentioning the hi cost for the hospital to purchase a claims system and to invest in advertising and promotion.  For those keeping track, it is a Physician Hospital Organization (PHO) of a slightly different color and we all know how successful and sustainable those were in curbing healthcare costs in the 90’s.

As a provider, I can think of several times when a common sense thing like “bundled” payment (or per visit) was tried in physical therapy only to suffer from the “system” problem-payor IT systems can’t handle and the administrative nightmares forced abandoning the “good idea”.  While systems improve and change and I am aware of many per diem contracts (most of them pay lousy in my experience), this is altogether different than a procedure that involves many providers and coordinating of services. 

As we have pointed out on this blog several times, there is no quick fix or innovation of healthcare.  When you hear of the “one great idea” look well beneath the hood.  A complex system like healthcare cannot be fixed by simple solutions.

Thoughts?

larry@physicaltherapist.com

Is it though? 

An 11-year old (Deniz Ince) noticed more pain in his finger joints and wondered if the pain was related to playing video games.  Ince's dad, a rheumatologist, must have introduced him to Yusuf Yazici, MD to assist in answering if playing video games contributed to finger joint pain in kids.

The 11-year old was listed as the lead investigator of the submitted abstract which was accepted at the American College of Rheumatology/Association of Rheumatology Health Professionals 2009 Annual Scientific Meeting.

Of the various game consoles and handheld units, the Wii was the only device associated with pain for all 7-12 year old kids regardless of how many hours it was played.

I loved Deniz Ince's thoughts on the Wii after his study was presented.  Based on the study findings, he is no longer playing video games as much as he was.

If an 11-year old boy can change his behaviors based on evidence, why do adults have so much difficulty?

photo by Ian Muttoo via Flickr

~Selena