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PTBA Position on Responsibility and Accountability for the Delivery of Care

Last week, we posted the current state of the RC-3, realizing that as HOD convenes in a few days in Tampa that there is all kinds of jockeying in regards to rescinding motions and what appears to be a very cryptic attempt to deal with something that at base is very easy to understand.  My hope is that such confusion won't paralyze the HOD from proceeding with something that has already passed by doing something lame like delaying implementation for the purposes of "exploration".  Hopefully, there will also be strong endorsement for Model 4 which is the most permissive model for PT's (and PTA's amongst other credentialed extenders of care acting while realizing that the PT is the responsible party).  The PTBA which was formed to improve business conditions for independent physical therapists has weighed in with the following well stated position below (full disclosure: I am a board member):

Physical Therapy Business Alliance (PTBA) Position:
Physical Therapist Responsibility and Accountability for the Delivery of Care

The Physical Therapy Business Alliance Board has carefully reviewed the 2012 House of Delegates discussions regarding the motions surrounding Physical Therapist Re- sponsibility and Accountability for the Delivery of Care. In addition, the Board has examined the extensive report and detail provided by the Delivery of Physical Therapy Task Force, established in 2011 by the APTA Board of Directors. The PTBA Board agrees with the philosophical stances that have been previously espoused: physical therapists have a responsibility to deliver services in ways that protect the public safety and maximize the availability of their services. Furthermore, physical therapists are practitioners characterized by independent, self-determined professional judgment and action; who have the capability, ability, and responsibility to exercise professional judgment within their scope of practice and to professionally act on that judgment to best meet the needs of the patient/client.

We now strongly urge the House of Delegates to promptly seize the opportunity to put those words into action by crafting and passing the motion that unequivocally states: That the American Physical Therapy Association (APTA) recognizes that physical ther- apy is provided by, or under the direction and supervision of, a physical therapist. In this critical time period of unprecedented health care change, the need to more firmly establish our profession as a thought leader in health care reform, and to provide visible evidence to today’s physical therapists that their professional association is relevant and intends to act with a complete understanding of current and future clinical practice dynamics, no dilution of this fundamental principle should be accepted. The diluted iterations of this fundamental principle should be seen for what they are: maintaining the historic prescriptive culture that has long contributed to the stifling cloud over all aspects of physical therapy from clinical practice, to policies and positions. If the pro- fession is fearful of innovating through a disruptive solution set, then it is completely out of synch with the drivers of today’s health care reform. 

 

It is time that the profession demonstrate that it fully understands the challenges, constraints, and economic realities that exist in the clinic today. It is abundantly clear and widely accepted that the definition of value in today’s health care system is HEALTH CARE OUTCOMES/COSTS INCURRED. Therefore, any argument that attempts to make a distinction between the issues of provision of physical ther- apy services and payment for those services suggests a position completely disso- ciated from the most important questions being raised in health care today – costs and outcomes. The two cannot be separated because they are both at the core of Value. If we, as physical therapists, are going to provide a value proposition to consumers of health care and simultaneously firmly establish our autonomy, then we need to demonstrate that we are willing to eliminate all aspects of the prescrip- tive nature of our historic culture. If we have any hope of changing our external communities view of us as an undifferentiated commodity, and instead guarantee that they see us as a people skill and knowledge based industry, then the moment has arrived to for the profession to embrace this paradigm shift. If we choose to delay and dilute, health care will move forward without us.

In summary, PTBA strongly believes, that it is in the best interest of the patient, the physical therapist’s ability to provide comprehensive and cost-effective care, and the totality of the influences that the physical therapy profession has the poten- tial to achieve, if the Delivery of Physical Therapy Task Force Task Force recom- mendation 4 is not only strongly endorsed, but emerges as the working paradigm for our profession.

Respectfully,
Physical Therapy Business Alliance Board 

We encourage APTA members to voice their opinions to their delegates. If you are not an APTA member, you should be. Click here.

@physicaltherapy

Another Economic Argument for Physical Therapy First

I just completed reading yet another research article to be published in Spine (accepted May 18, 2012) that examined the economic consequences of early physical therapy management for treating low back pain patients. Specifically, this study evaluated a large sample of low back pain patients (32,070) where a low percentage (7%) utilized physical therapy within 90 days of being examined by their PCP. Those patients referred to PT early (within 14 days) demonstrated decreased likelihood of consuming advanced imaging, additional physician office visits, surgery, injections, and opioid use. While the PT outcomes were not examined in this study, it can be assumed with some confidence that reduced subsequent medical service utilization was a function of condition improvements.

This study highlights several points that need to be raised. Firstly, there is absolutely too much variation in the management of low back pain. A recent data-set of UHC commercial claims shows that the greatest cost-driver in medicine today are orthopedic related and accounts for 17% of all expenditures (greatest percentage being spent on spine management). This demographic is largely driven by prevalence of back pain. When we assess health consumers treatment options for back pain there are literally 11 different provider options as access points. The above referenced study demonstrated that only 7% of patients were referred to a physical therapists for their low back pain. This referral percentage is entirely too low and is also supported by the research of Gellhorn, L. Chan et. al. 2010. They too concluded from their study that early PT management decreased downstream lumbar surgeries, spinal injections, and frequent physician office visits and suggested that generalists/ PCPs likely underutilize physical therapy referrals.

This brings me to the next point-- all back pain is not the same. That is, the traditional medical model hasn’t effectively evolved to efficiently manage spine problems. Currently, the US treatment guidelines for the management of low back pain are generic and do not differentiate treatment subgroups based on clinical presentation. Being a physical therapist, this is a source of extreme frustration. How many times have you heard from patients suffering from low back pain, “Why hasn’t my doctor sent me to your earlier?” or “I wish my mother, sister, father had seen you prior to their back surgery”. The answer is simple; most physicians do not understand how to effectively perform an orthopedic spine examination and certainly don’t understand how to differentiate subgroupings of LBP patients. This is true for orthopedic surgeons, GPs, neurosurgeons, nurses, and physician assistants. Our physician colleagues have grown too dependent on imaging and too often conclude structural abnormalities are the definitive cause of a patients’ pain/problem. This is largely a function of defensive medical practices, and reduced time per patient that has been promulgated by a runaway fee for service remuneration model that rewards procedures and self-referral.

Also, this research article suggested reduced use of opioid utilization among LBP patients when they have been seen by a Physical Therapist within 14 days of seeing their PCP. This was also demonstrated by an earlier study published by J Fritz, J Cleland et. al. 2008 which concluded that early management of low back pain patients by physical therapists decreased likelihood of patients incurring high charges for subsequent healthcare to the tune of $1,304 or 37% less downstream costs. While it is difficult to quantify the economic impact of using narcotic prescriptions to manage low back pain, it is clear that this problem is growing and likely impacts in-direct costs much more than direct costs. I hate to rant, but I am appalled by the proliferation of pain clinics. Most are driven by ineffective management of pain syndromes that originate from the accumulation of undiagnosed movement dysfunction. Ultimately, many of these cases, who should be in our doors and under our care, are sent on a treatment path where there is no return. Treating chronic low back pain as an acute injury only facilitates more of the same.

Lastly, this study showed that medical resource utilization was actually higher when PT was initiated late (15 to 90 days) post initial PCP visit. In 2010, I was presented with similar data from the nation’s 3^rd largest Medicare Replacement Plan asking me why there was so much variation in out-patient PT ($) spending per member per month among their many Independent Physician Organizations (IPA). After reviewing their physical therapy spend data among local, regional, and national IPAs it was clear that there was huge variation in how PT was being utilized from IPA to IPA.

I concluded that this company was “asking” the wrong questions when analyzing this data. I advise them and their actuarial department to compare overall orthopedic spends (Imaging and Surgery by ICD 9 Code) for those IPAs with high PT utilization with those IPA with low PT utilization. My hypothesis was that those IPA with high PT utilization would demonstrate much lower downstream orthopedic costs. After running the data that is indeed what we found. When PT was utilized early the downstream orthopedic spend was much less. The data suggested that the timing of PT strongly correlated to the downstream spending per patient per month—this data suggested that when PT was seen first the imaging and the surgical spend was significantly lower. This analysis also showed that IPAs who used PT aggressively also demonstrated lower in-patient and out-patient rehab costs within the patient populations they managed. See below a chart summarizing one facet of this analysis:

ALL MARKET	885,691		mm
	recd 97001 timing
Category	after	before		no 97001	same day	Grand Total
Knee Imaging	$ 0.00	$ 0.00		$ 0.02	$ 0.00	$ 0.03
Knee Surgery	$ 0.01	$ 0.00		$ 0.06	$ 0.00	$ 0.08
Low Back Imaging	$ 0.13	$ 0.09		$ 0.84	$ 0.01	$ 1.07
Low Back Surgery	$ 0.27	$ 0.14		$ 0.66	$ 0.04	$ 1.12
Neck Imaging	$ 0.06	$ 0.05		$ 0.51	$ 0.00	$ 0.63
Neck Surgery	$ 0.01	$ 0.00		$ 0.02	$ -	$ 0.03
Shoulder Imaging	$ 0.00	$ 0.01		$ 0.01	$ -	$ 0.02
Shoulder Surgery	$ 0.39	$ 0.17		$ 0.62	$ 0.00	$ 1.19
Grand Total	$ 0.88	$ 0.47		$ 2.74	$ 0.06	$ 4.15
HENDERSONVILLE IPA	33,257	mm
	recd 97001 timing
Category	after	before		no 97001	same day	Grand Total
Knee Imaging	$ -	$ 0.00		$ 0.01	$ -	$ 0.01
Knee Surgery	$ 0.02	$ -		$ 0.03	$ 0.06	$ 0.11
Low Back Imaging	$ 0.08	$ 0.03		$ 1.09	$ -	$ 1.20
Low Back Surgery	$ 0.91	$ -		$ 0.26	$ 0.13	$ 1.31
Neck Imaging	$ 0.08	$ 0.01		$ 1.37	$ -	$ 1.46
Neck Surgery	$ 0.16	$ -		$ 0.06	$ -	$ 0.22
Shoulder Imaging	$ -	$ -		$ 0.01	$ -	$ 0.01
Shoulder Surgery	$ -	$ 0.23		$ 2.04	$ -	$ 2.26
Grand Total	$ 1.25	$ 0.27		$ 4.87	$ 0.19	$ 6.58

This table illustrates, that when PT was utilized before an orthopedic consult, downstream orthopedic resource use was much less. For “All Market” the overall orthopedic spend, when PT was accessed before orthopedic consult, the resource use was $.47 per member per month; while the orthopedic spend was $.88 per member per month when PT was accessed after an orthopedic consult. While there where several limitations to this claim based analysis, it did suggest that a more formal and highly controlled research approach should be conducted to examine closely the downstream orthopedic costs.

Collectively, our profession needs to use the clinical and the economic evidence (as highlighted above) to obtain receptive ears with legislators and health policy experts to discuss how physical therapists should play a primary care role in the management of all musculoskeletal problems. The above referenced studies clearly suggest a physical therapy triage first model may make good economic sense. A “PT First” approach would also assist with improving patient access to the right provider at the right time while delivering value to the consumer and to payors. The current system isn’t meeting the public’s needs or expectation with regards to managing musculoskeletal problems. We must use this data and be confident in demonstrating our value to the health delivery system and the public; use this data to assist with obtaining unrestricted direct access across all states, and educate our loyal patients to be advocates for the services we provide.

Dr. C. Jason Richardson, PT

Sr. VP of Clinical Operations

Results Physiotherapy Centers

Is Adverse Reponse to Exercise a Rare or a Common Event in Physical Therapy?

We just don't know.

This study Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence? was reported in PLoS One yesterday (online).

This is the first study like this I've ever seen. According to the study authors:

"Whether there are people who experience adverse changes in cardiovascular and diabetes risk factors has never been addressed."

This just underscores the need for physical therapists to monitor basic, cardiovascular signs in response to exercise.

• Blood pressure
• pulse
• respiratory rate
• oxygen stauration
• rate of perceived effort
• et al

Acocrding to Jette and Jewel in the April 2012 PT Journal:

• only 11% of physical therapists routinely measure blood pressure
• only 38% of physical therapists routinely measure Body Mass Index (BMI)
• only 21% of physical therapists routinely advise patients to quit smoking
• only 29%% of physical therapists routinely complete a neurological examination in diabetic patients
• only 26% of physical therapists routinely complete a footwear examination in diabetic patients
• only 6% of physical therapists routinely measure gait velocity in their older patients

I'd like to see physical therapists advocate to change our state practice acts so that we could penetrate the skin and collect blood samples to measure important factors in assessing exercise response, included in this study:

• fasting plasma HDL-cholesterol (HDL-C)
• triglycerides (TG)
• insulin (FI)

At least one state physical therapists' association was successful in 2011 in increasing their scope of practice to allow penetration of the skin.

But, before changing state practice acts we need to measure the basic stuff.

Otherwise we'll never know.

Tim Richardson, PT

PhysicalTherapyDiagnosis.com

"Tyranny of the OR" Why RC3 Should be Implemented

The upcoming APTA House of Delegates (HOD) has what appears to be a very full agenda with many items that have a significant philosophical impact on the profession-most notably what to do with RC-3.  (if you are not a member of APTA, you should be, click here).   This blog has weighed in many times on the RC-3 issues.  By way of reminder, RC-3 passed last year which in its most basic form is to  align with what is done in the real world of physical therapy  (in most state practice acts) with respect to delegation and supervision of support personnel versus what APTA (and medicare) promote which is a restricted view of what a PT can do in regards to decision making.  While it passed the house, implementation was delayed for a year and a task force with an acronym as obnoxious as HPPIDPT was formed (full disclosure, I was on this "Health Professionals and Personnel Involved in the Delivery of Physical Therapy Task  Force).  The work product of this group produced amongst other charges an outline of four models of care for consideration ranging from the most restricted (basically APTA/Medicare's current positions) to the most permissive which would allow PTA and other PT extenders a role in intervention and selected components of examination and evaluation while clearly under the guidance and responsibility of the physical therapist.  Impressively, APTA's Board passed a resolution supportive of exploring this most permissive model.  Ironically, this resolution has the unintended consequence of further delaying progress in the name of progress.  Some might call it "analysis paralysis".  My interpretation is that it is an easy excuse by the HOD to not act on what has already passed.  If there is one consequence to fear, it should be credibility.  No wonder this recent guest post graded APTA an F in the area of physical therapist's autonomy.

 

Here is an example of the type of communication that is being spread in light of the "exploration of model 4":

There are basically three choices facing the delegates:

1.    Delivery of PT care stays the same

2.    Look at proposed changes & take more time for consideration

3.    Make changes now that go into effect 7/1/12 and deal with the effects/consequences

Can we agree that options 3 is intended to invoke fear of the unknown?  Isn't that throwing in a little bias? 

Jim Collins in his great book Built to Last describes a phenomenon that I think is at play here.  It is called "Tyranny of the OR" which he defines as the rational view that cannot easily accept paradox, that cannot live with two seemingly contradictory forces at the same time.  This pushes folks to believe that things must be either A or B, but not both.  This leads me to believe that it will compel delegates to likely take more time for consideration and this would indeed be a shame and further support a restricted role of the HOD.  The fact is that RC-3 passed and implementation is progress. The reality is there is zero effect or consequences to be worried about.  It is a step in the right direction and of course further progress in studying the most permissive model should occur (my hope is that it eventually passes).  Let's encourage delegates to adopt an alternative that Collins' describes as "Genius of the AND" which is to embrace both extremes of a number of dimensions a the same time.  In other words, you find a way to have both A and B (or in our case #3 and still explore).

 

Please communicate your thoughts to your delegates-that is one responsibility that we can all agree.

 

Thoughts?

 

@physicaltherapy

Happy Memorial Day from EIM!

This article about the role of PT in Afghanistan appeared on the front page of today's New York Times and is a fitting tribute to physical therapists on Memorial Day.

Rachel Odom is a recent graduate of the US Army-Baylor DPT program, a terrific testament of the profound contributions that an "inexperienced" PT like her can make on the health of our troops and their ability stay in the fight. Never underestimate the youth of our profession and their potential to be difference makers. We have a long ways to go to better understand the qualifications for being an "experienced" PT. I have no doubt that after a year in Afghanistan, Rachel will be a highly experienced PT who I'd take on my team anytime.

EIM salutes the numerous physical therapists associated with the EIM community who have ever served in the military. Thank you for your dedicated service to our nation!

The EIM Team

The APTA’s Vision 2020: My 12 Year Report Card

We are please to be able to have Allen Besselink guest post.  Allen has a an excellent website and blog which we highly recommend and you can also follow him on twitter.   

 

We are now into year 12 of the APTA’s 20 year “Vision 2020” mission statement. With the APTA National Conference right around the corner, I think it is important to assess the accountability of the organization in meeting the goals of Vision 2020. I would like to believe that the association exists to serve the membership, and thus here is one member’s personal report card.

For those that need a refresher, here is what the APTA’s House Of Delegates put forth in 2000: “By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”

So with that said, let’s take a look at where we stand on all of this, 12 years down the road.

First, a quick history lesson of sorts.  The entry-level physical therapy degree is that what is required to take the state licensure exam. Although you may have a physical therapy degree, you still have to pass a licensure exam in order to practice as a physical therapist.

A number of years ago, the entry-level PT degree in this country was a Bachelor’s degree. This is still currently the standard in most countries around the world. Also, it is important to note that foreign-trained physical therapists must still pass the licensure exam, regardless of their own entry-level degree, if they are to practice in the United States. Licensure is “the great equalizer” in terms of professional education.

Over time, the APTA forged ahead with a goal of having a Master’s degree as the entry-level to practice. With Vision 2020, the entry-level degree would become a Doctorate degree.

With that background information, here is my Vision 2020 report card. Each of the six primary elements of Vision 2020 are noted, along with their separate operational definitions per the APTA.

Autonomous Physical Therapist Practice. “Physical therapists accept the responsibility to practice autonomously and collaboratively in all practice environments to provide best practice to the patient/client. Autonomous physical therapist practice is characterized by independent, self-determined, professional judgment and action.”

If you are in a room of 10 physical therapists, you won’t get agreement on what professional autonomy looks like, yet in reality (and from a medico-legal perspective), all practice with “professional judgment and action”. For some reason, this has become more of a self image problem than anything else.

The defining issue of professional autonomy is the state licensure exams and practice acts. 

Grade: F. A self-image extreme makeover would be beneficial.

Direct Access. “Every consumer has the legal right to directly access a physical therapist throughout his/her lifespan for the diagnosis of, interventions for, and prevention of, impairments, functional limitations, and disabilities related to movement, function and health.”

As of year 12 in the APTA’s 20 year “Vision 2020” mission, there are 17 states with real, gatekeeper-free direct access and professional autonomy. But interestingly enough, we had that same number (or thereabouts) at the start of this 20 year venture, doctorate degree or otherwise. Remember that 20 years ago, the entry-level degree was a Bachelor’s degree. A change in entry-level degree, yes, yet no change in access.

What makes this worse is that the APTA continues to talk about varying “shades” of direct access. As a consumer, you either have it or you don’t. And most don’t.

Grade: F. Ask the consumer about direct access. If they are even aware that the issue exists, let me know.

Doctor of Physical Therapy and Lifelong Education. “The Doctor of Physical Therapy (DPT) is a clinical doctoral degree (entry level degree) that reflects the growth in the body of knowledge and expected responsibilities that a professional physical therapist must master to provide best practice to the consumer. All physical therapists and physical therapist assistants are obligated to engage in the continual acquisition of knowledge, skills, and abilities to advance the science of physical therapy and its role in the delivery of health care.”

The operative terms here are that the Doctorate degree “reflects the growth in the body of knowledge and expected responsibilities”. If that is truly the case, then I am not sure how any foreign-trained physical therapists are surviving the licensure exam with their entry-level Bachelor’s degree. Just what does a 3 year doctorate – with fewer clinical hours than many of the old Bachelor’s degrees – actually provide in terms of “value-added benefit” for the graduate or, better yet, the consumer?

Graduates are now faced with a financial burden that is oftentimes in excess of $100,000 in student loans which, by the way, is on par with lawyers and with far lower return on investment over both the short- and long-term. An annual tuition of, get this, $43,000 is not uncommon. DPT programs have not provided any associated increase in the ability to earn greater income than when the entry-level degree was a Masters degree or, worse yet, a Bachelor’s degree. My $25,000 degree in 1988 would be worth $50,000 today given a 3% cost of living increase per year.

The profession was told, quite explicitly, that there would be a significant impact of the Doctorate degree on consumer awareness. The entry-level Doctorate degree was going to be the be-all-and-end-all to our professional autonomy. Sadly, the data has yet to reflect this claim. As it stands right now, I would call this a case of degree bloat – no more, no less. There is no increase in professional responsibility with a Doctorate degree, but there is a significant increase in financial investment.

Grade: F. Ask the new graduate about their return on investment.

Evidence-based Practice. “Evidence-based practice is access to, and application and integration of evidence to guide clinical decision making to provide best practice for the patient/client. Evidence-based practice includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health care policy decision making. Aims of evidence-based practice include enhancing patient/client management and reducing unwarranted variation in the provision of physical therapy services.”

Educational programs continue to struggle with this. They continue to spend time and effort teaching students assessment and treatment interventions that have little to no scientific support. This is usually done under the premise not of clinical reasoning but that “you will need to be aware of this when you are practicing”. Educational programs could simply choose to not waste their time and efforts on these issues, and spend the time on important issues like clinical reasoning, thinking, and effective communication skills. Part of this is defined by accreditation standards which may or may not reflect evidence-based clinical guidelines.

Grade: F. Educational content has remained pretty similar over the years, but the entry-level degree has changed. Hello?

Practitioner of Choice. “Physical therapists personify the elements of Vision 2020 and are recognized as the preferred providers among consumers and other health care professionals for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.”

Patients will never see physical therapists as the practitioner of choice if they can’t freely access them. Patients don’t have the right to choose. They have to go to a gatekeeper first in 33 of the 50 states. Simply stated, our level of recognition as “practitioners of choice” will go hand-in-hand with direct access.

Grade: F. Ask a patient who their first choice is for back pain, and let me know what they tell you. Can you say “chiropractor”?

Professionalism. “Physical therapists and physical therapist assistants consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities.”

Fortunately, this has never seemed to be an issue with the profession. The APTA continues to be a strong advocate for professionalism. The profession, as a whole, seems pretty comfortable with this concept clinically.

Grade: A. Let’s all sing “Kumbaya”, we can celebrate our professionalism while we avoid the 800 pound gorilla(s) in the room!

Summary:

I have been a physical therapist for 24 years. I was trained in a different country, and practiced there as well. I have been a member of my professional association for the majority of the time that I have been a physical therapist.

I have the privilege of working alongside patients, other clinicians, and students – so I am not getting a limited perspective. I am practicing in a state (TX) that the APTA claims is a “direct access” state, but the practice act certainly does not reflect that whatsoever.

It is my professional opinion that the primary issue affecting physical therapists in this country – that of direct access and professional autonomy – has been mishandled and misguided over the past 12 years if not longer. The APTA's current stance on these issues is disheartening at best. While the academics are busy glorifying themselves with their advanced degrees, the profession as a whole is still in the dark ages in terms of licensure and autonomy.

With that said, and with accountability key, I would urge the APTA to use the next 8 years to revise their strategy. As they say, if you do what you’ve done, you will get what you’ve got. Sadly, what we’ve got isn’t much different than what we had 12 years ago.

Allen Besselink

Manipalooza Visit-Dr. Childs Visits

Always great to do special things at Manipalooza which just finished.  Best part was being able to fly John Child's in from Afghanistan for the event.  Since he had to get back to quickly, we thought we would make a movie chronicling his visit-even added music and production credits.  Enjoy!

 

Body Wash, Shampoos, Conditioners and Bars

"Hey Josh Cleland, how many times have you filled your shampoo/conditioner/soap bottles?"

Wouldn't that be the most perfect question ever that would correlate Josh's training commitment with his hygiene? I mean, we committed to our individual personal adventures back in November, so we're at a stage for bragging rights on just how much training we've done. Josh didn't smell of chlorine back in February the last time I saw him, so I know he's showered.

"None." "HaHa... Well, I KNEW you probably didn't use shampoo or conditioner. Okay, how much body wash have you gone through?" "Oh, probably 20 bars."

My whole blog post is now a fail... thanks, Josh! I most certainly was not anticipating that Josh used bars of soap! Ladies, we need to help Josh out on the benefits of body wash! By the end of the year, we have to convert him to being a liquid body wash kind of guy! Body wash care packages coming your way, Josh! ;)

Now what do I do? I've filled my little 3 oz bottles 5 times since November (rocking out on my commitment) and Josh has gone through 20 bars of soap.  Is he talking the hotel bars or the big 'ol Irish Spring bars?

We have this same sort of problem comparing published literature outcomes with real life patient outcomes. In thinking about body wash, Josh is much bigger than I am. To lather up his body is going to take a lot more product than it will mine. But... if I decide to shave my legs in the shower, well, that's going to alter my usual and customary amount of body wash. (Now... FYI, I don't shave in public showers, but I have seen it done.) Depending on the product and how it comes out of the bottle can also be a factor in just how much product is used to lather up. If you have to yank the lid off and use your finger to snag some out, you'll use a lot less than if it just easily squeezes out. After exercising as proprioception and coordination decrease due to fatigue, if you drop the bottle, then you have spillage which increases the amount of product used too. The viscosity of the product also needs to be considered. The nice thick ones with moisturizers don't come out as easily as some of the manly, man body washes. Do I dare say that I bet more body wash is used after swim training than after run or bike training? There's just something about trying to rid oneself of the chlorine odor that automatically means more body wash would be used.

One of the frontiers evolving over the last 20 years is that of outcomes. Outcomes will be a relevant factor in the future. We have more and more literature publishing outcomes - which is great! We need to be careful though... as we move into using outcome data to support our value, we really don't have a standardized measuring system. What we have is as bad as the shampoo/conditioner/body wash scenario. We really do need to have many of the variables that affect outcomes accounted and considered in the reporting mechanism. Since the big push in the federal system is some alternative payment system for outpatient physical therapy services, we need to think... if claims are going to just be analyzed on an individual basis, I'll make up a word - an intra-patient analysis, then, we're probably okay with using the tools we have. I doubt the future will stay at an intra-patient analysis though and the claims data or outcome data that will probably be submitted on each patient will probably be dumped into a database and inter-patient analysis will happen. This is a huge mistake... Josh and I both started committed training in November. I've refilled my bottles 5 times and he's used 20 bars of soap. How do we analyze that to determine who's more committed?

And, since some have asked... the training update. Josh has been killing it through and through. Two 90 minute swim training sessions... I think he recently did a really long bike race? Long like over 50 miles... and I can't remember the distance he's running, but in the 20 something mile range. (Honestly, I didn't save his updates... I do know it was LOTS of training though.) Guess he has good reason to use 20 bars of soap! His first event of the year is the Mooseman Half Ironman on June 3rd.

I'm killing it in the water! I've got my mile pace down to 34:29 minutes which I am really, really proud of! <sigh> I've only been on my bike three times. I'll admit, I'm slow to change - I'm a girl of habit and just haven't committed to bike training, yet. And, I'm in the 3-4 mile range running depending on the day. My first event of the year is also on June 3rd and it's the Hawk Island Sprint Triathlon.

Obviously, Josh should be using quite a bit more body wash than I am. Let's say I did train at the same level as he is... would the use of our hygiene products accurately capture our training habits? Are we going to have the same problem in the future if the powers that be analyze claims data?

Talk to you later,

~Selena

photo via Flickr by takot

Direct Access - You ARE ready!

Where's our confidence?

Tim Richardson recently posted on the upcoming primary care physician shortage. I was going to comment there, but my comment deserves more space & time than a comment.

Recently, via a 4/24/2012 tweet chat on #solvePT discussing direct access, I learned something huge! Via those who contributed their thoughts, the majority aren't embracing direct access! When I see statistics of 15-20% of patients self-referred, that immediately tells me we aren't believing in our value. We are choosing to focus on payer obstacles and barriers. We are choosing to not rock the boat with physicians in the community because we don't want to burn a relationship. Although these are valid perspectives, who are we hurting? We are hurting consumers by our timidness; we are hurting our professional integrity. You read that right... our integrity. We aren't being honest with ourselves with the talent and skill we bring to the world or with our value.

Squeamish about the responsibility of direct access? Fearful of the accountability of direct access? Afraid you'll hurt a physician relationship? I'd like you do do a tad bit of self-reflecting. Does that piece of paper a physician gives to a patient referring to a physical therapist truly tell the whole story? You ARE ready to be a solution in this train wreck of health care!

Take some time to read a thought provoking article by Michael Ross & William Boissonnault (love their work, by the way). Their research doesn't even tell the whole story. Think of the patients you have treated in the past. All of mine are referred from a physician. I don't have time to report case studies on my experiences and neither do you. But I KNOW we aren't a threat to society OR to a physician. I refer back to physicians or specialists ALL the time! Let me give you a quick run down of just a few examples from my career... spinal infection, missed cervical fracture, internal bleeding, drug toxicity reaction, tibial stress fractures, polymyalgia rhematica, depression, myocardial infaction, other cardiac issues, post op infections, blood clots, cancer, suicide, Parsonage-Turner Syndrome, low Vitamin D, shingles in an adolescent, femoral head/neck necrosis... This "relationship" we have with physicians is SO not one-way in nature.

Although all my referrals come from physicians (Michigan is NOT direct access), I view myself as THE musculoskeletal expert. My role is to focus on who needs treatment, who needs further diagnostic testing, and who needs a referral to a specialist. In situations where a patient needs to be referred, my role is to help the physician understand what needs to be ruled in/ruled out. My role is to anticipate expected responses within a defined period of time and to re-evaluate my clinical decision-making when the anticipated responses do not occur. That even means going right back to square 1 and asking is the patient appropriate? Just because a patient walks in with a referral from a physician is by no means an excuse to turn off my clinical, critical thinking. I cannot and will not assume the physician knows best 100% of the time. Physicians need us and our expertise... consumers need us and our expertise.

Direct access is just a law as to how your patients are able to receive your services. Your actions and behaviors with regard to patient care and decision-making should be no different whether you have direct access or not. Our profession is SO ready to step up to plate and be of assistance in this time of need. Nurses aren't the answer for musculoskeletal problems; physical therapists are THE answer.

When will we express our confidence in this type of role? Practice environments will evolve and change to where we traditionally may not be in an outpatient physical therapy clinic. We do not need to be segragated to a traditional clinic - we can practice shoulder to shoulder with physician assistants, nurses and physicians. All it takes to make it happen is triaging phone calls; triaging patients to the best capable provider to resolve the reason medical attention is being sought.

We are ready. Why don't we believe in ourselves? Why aren't we confident we can deliver?

Talk to you later...

~Selena

April #Physicaltherapy filings

I though the ending of  March Madness would have opened up some blogging time but between Springsteen's tour, Kentucky Derby Festivities, and the #solvept movement,  you just have to have your priorities straight.   Because my desk is so full of files, I am going to have to separate this post into two parts.

But first, by way of announcements, I am looking forward to Manipalooza on May 19th. We are doing the 15 min short talks in the morning followed by a business track option in the afternoon which will include a fun case study about the Patient from Hell.  My  short talk is centered on the "outside view" or using perspectives and research from completely outside physical therapy to help solve problems that we face within physical therapy.  Hope to see many of you there.

I am also excited to announce that the Private Practice Section in conjunction with  EIM, the Physical Therapy Business Alliance (PTBA) and Bellarmine University will be co-hosting the Graham Sessions June 2 from 8-4:30 pm in Louisville at the Hilton Garden Inn.  The Graham Sessions are a series of forums for debate and discussion to drive the physical therapy profession forward.  The Annual Graham Sessions are hosted by the Institute for Private Practice Physical Therapy, PPS, and APTA.  With a need to expand discussion regionally in order to gain a broader range of solutions to the issues we face as physical therapists, the regional Graham Sessions were developed.  I have had the pleasure of attending many of the Graham Sessions and for those of you who attend it is a great day of debate, networking, and some inspiring short talks.  Here is one of my favorite bloggers Tim Richardson's perspective on his attendance at a regional conference.  The event is no cost and an added bonus is the user pay option of attending Churchill Down's night time races on Millionaire's Row of which will include admission, racing program, and a buffet dinner!  For more information contact Laurie at privatepracticesection@apta.org.  

 

Ok, now for some quick thoughts:

File under #more to this picture:  

There is an on-going trend both within the profession and by payors to equate lower visits with better outcomes.  I personally think you can make an argument based on some compelling data that would show visits are essentially an independent variable in the outpatient setting. Factors that go into it fall well outside of just what the PT thinks or what a referral source may send.  Copays and gas prices often have a big impact on visits (side note: great to see many states following our KY example of fighting for copay legislation).  In addition, you have to look at recidivism, comorbidities, independent outcome data, and entire episode of care to name just a few.  A compelling case that PT is underutilized is easier to show than low visits are better but let's not let common sense get in the way of payor policy.  An outstanding provider that I know well was just informed that they are now Tier 2 or some arbitrary classification by a payor who shares the same first name as my least favorite airline.  The reason is that their average number of visits are higher than other providers in the area.  The irony is that more and more providers are opting out of this payor because their reimbursement is less than an oil change.  But for the sake of argument, let's play their logic out.  What if there were 8 providers in an area and each provider discharged the patient after one visit and sent them to another PT provider.  This would bring the average visit per patient down to one per the 8 providers and all would be classified as Tier 1.  The patients out of pocket would be the same and in theory the payers amount to providers would be the same.  Maybe this is the right strategy for the absurdity of provider profiling with this payor.

 

File under #fear of consequences:

There is an interesting bill in the making in Missouri.  At this stage, I am unsure where it is at but the idea is to compel payers to equally pay PT providers whether they are based as employees in a hospital or as independent providers. Of course, hospitals don't want to support because they extract higher fees from payers.  While I believe that hospitals really do need us, I can totally understand their concern as private practices have generally done a horrific job of negotiating rates and certainly don't have much leverage in the marketplace with payers.  On the other hand, the assumption that payers will just lower rates to everybody is a little premature as well.  Hospital's yield incredible power legislatively and I can't imagine this bill has any chance.  Hospitals lean toward monopoly or oligopoly and are never in the mood for real competition.   Lately, they  have gone on buying sprees of their competition in a serious threat to payers.  Interesting times for sure.

File under #misery loves company:

Despite the fact that RC-3 passed last your at APTA's HOD, there appears to be an odd end run around by the New York Chapter which arguably happens to also be the most regulated and lowest reimbursed physical therapy state in the U.S..  RC-3 which essentially allows PT's to practice within their practice act and evolving healthcare delivery versus antiquated and stifling current "rules" by APTA and CMS, is scheduled to go into effect this summer.  While it passed a year ago, it's implementation was put on hold pending additional work in defining models of care which I believe are available on APTA communities page (full disclosure, I was one of many on that workgroup).  At least drafts that I have viewed, have NY introducing a "position" that essentially affirms that the only folks who can share oxygen in the same room with a patient are a PT and PTA.   It always strikes me as hypocrisy that we fight for direct access under the logic that a PT has appropriate education and judgement  but at the same time we want to limit that judgement when it comes to using extenders.  There is also a strange fear that if a PT can use extenders that hospital's, MD's, and others will just hire techs to provide physical therapy.  Underlying everything within the profession of course is the principle that a physical therapist is what makes it physical therapy and the PT has to be completely involved in the patient's care but let's not get lost in such a simple, fundamental concept.

April was a busy month. More later.

Thoughts?

@physicaltherapy