My All PT’s are Crooks satirical post generated some comments and caused an overload to my email inbox. The overwhelming response was positive and most found humor in it. Many shared with me interesting and compelling stories of their experiences with many of the issues addressed in the post.
My writing is a product of my own conclusions and based in large part on the increasing regulatory trend as well as more emphasis on coding and compliance training rather than evidence-based practice. The genesis of it has been influenced by discussions with private practice PT’s , comments and interpretation on various listserves, articles in our journals, presentations, participation in last years public Rothstein debate, and my work in practice management where fear over these issues are palpable. Some of the issues (e.g. can’t open up our practice act), I have heard for 25 years. My recent exposure to what is going on in California with PT’s caving to their state’s largest payor out of fear and the arguments that I have been hearing out of New York to PT’s who are trying to make positive changes in their practice act took me over the edge. Let’s not forget the most obvious-this is a blog where opinions are openly shared and comments are invited.
Let me first be clear as to what the post was NOT. It is not an indictment against any individual person, CE course, company, product, or association. The issues are an amalgamation and a reflection of what I see in practice and my concerns regarding significant over regulation and what it is doing to patient care-reducing us to technicians which ultimately is resulting in downward reimbursement rates and making private practice viability a real concern.
It is clearly the responsibility of PT’s to know “rules”. Furthermore, it is incumbent on them to not only follow them but to have systems in place that assure compliance. On this level, it is akin to college coaches following NCAA guidelines-may not like the “rules” but they have to be obliged. It is understandable that there many courses, consultants, attorneys, and experts in this arena. In my practice environment, we have created a “Dummies guide to medicare” complete with a quiz and annual training including corporate compliance and discussions regarding coding and billing examples. We take the philosophy of embracing compliance as a method of improving care but do so in an unintimidating and fun environment. Scaring PT’s and staff doesn’t benefit anybody and I have personally seen tense and intimidating environments where I believe there is too much emphasis on this stuff. I do believe that compliance and some regulations are important cogs of the system-but further believe that the pendulum has gone grossly overboard. For those that cry out for more regulation because of widely publicized fraud cases, they need to be reminded that in almost every case there was deliberate and malicious intent to violate the laws. I believe that almost all PT’s want to do the right thing.
It is my further contention that the cumulative impact of all of these “rules” has caused a practice environment that I would describe as “scared” since there are way too many of them and they are often at odds with licensure and even more often conflict within different payors-thus causing more and more time to be spent discerning. While I understand the “default” portion to just “follow medicare rules on all patients”, I think that is a disturbing trend. All of this results in significant time in over documentation, time calculation, and coding interpretation that takes away from patient care. I would invite you to view a presentation that I first saw at TED last year by Barry Schwartz who powerfully argues how often rules fail us. This point was driven home to me recently when I was reminded by medical providers how liberating their experience in oversees medical missions where they are unbounded by onerous regulations.
The unintended consequence and overall impact of all this has transitioned our practice to an arbitrary salary cap, a “billable” minute service time unit that is incredibly restricting, and an on-going reduction in the ability of a PT to use their professional judgment at the same time that PT’s are now going to school for 7 years and receiving a doctorate (keep in mind that outpatient PT is less than 1% of the medicare budget) . We have published in a previous post through the use of independent benchmark data that shows if a practice saw 100% medicare patients that the max earnings on a PT is about 70k. Can you imagine what it is in states where routinely the reimbursement is about 60% of medicare? States that are the most regulated (sorry New York) also have the lowest reimbursed rates. I don’t think this is coincidental but the accumulation of devaluing our services and reducing them to a set of “do’s and don’t’s”. I don’t know of any “doctoring profession” that takes away the ability to use discretion and professional judgment the way we do in PT. My colleagues in NY tell me that the average PT has to see 16–25 patients per day without the use of extenders to remain viable. Isn’t that a little concerning on quality care? Many in that state are adamant that they should not “true up” their practice act with the model practice act or with essentially all other states which allow for extenders. Their claim is that this is unbecoming of a PT to use support personnel, demeaning to the profession, and other emotional arguments that at the end of the day basically reflect that PT’s are incapable of using their brains and use of discretion concerning clinical reasoning, delegation, supervision, and direction of services. Isn’t it at least a little odd that in environments like the military and sports medicine, where direct 3rd party reimbursement is not of concern and outcome is of most critical importance that they liberally use support personnel under the direction of a PT (and those environments have a very high percent of board certified specialists, published research, and residency trained PT’s) . We are seeing great examples of PT’s teaching rehabilitation techs in Haiti right now of basic procedures and interventions since there are clearly not enough PT’s to go around such devastation. Do the same PT’s that think PT’s should never use extenders likewise see these unlicensed rehab techs as demeaning to our profession?
Some further examples of practices paralyzed in their attempt to follow the rules:
PT’s who don’t bill for all they do under the mistaken view that that they are being “nice” or not at risk for compliance problems.
Applying medicare's superimposed rules to all payors and believing that all care has to be 100% direct on one one between a licensed PT or PTA and a patient (by the way, if that is your belief that is fine but please stop telling everybody who doesn’t follow your belief that they are not ethical)
On non-medicare patients, not using support personnel on any aspect of patient care because of the mistaken belief that AMA CPT codes don’t allow it and that the codes trump state practice acts and licensure
Counter-intuitive definitions for things like “group therapy” including bizarre scenarios of what you have to bill when you have a medicare and a non medicare patient having overlapping times
Not billing manual therapy if it is less than 8 minutes
State associations not trying to make modifications to their practice acts under the very strange belief that opening them puts them at risk for losing certain privileges
If my crook satire post results in PT’s being less “scared” in their clinic environment, charging for exactly what we do, not signing contracts below cost, and creates movement towards ending further regulation and rolling back existing ones that impair patient care then it will have been successful. Judging by the many emails that it did in fact both strike a nerve and made people laugh, I deem it already successful! We should deliberate and debate these issues openly in the hopes that it drives real change.
Lastly, I obviously don’t believe that all PT’s are crooks. Like any profession, there is a very small minority that ignore the rules and an even smaller minority that blatantly practice against them and commit fraud. I don’t think it is helpful for the overwhelming majority of PT’s who follow “the rules” to get more “rules” simply because of the vocal minority. We have “regulation fatigue” and should be resisting further changes and fighting to ratchet back the many we currently have.
thoughts?
larry@physicaltherapist.com
