Sick of the mounting paperwork? Trying to keep your hours documenting to a minimum while still getting reimbursed? While the profession has always had to deal with denials and the ever-shifting target of “defensible documentation,” in the past year we have also added different evaluation codes based on complexity to our documentation headaches. This administrative burden has been growing, slowly but surely, over the past few decades. In a 1991 article in the New England Journal of Medicine, the authors described medicine as a “spectator sport,” one that is performed before “an enlarging audience of utilization reviewers, efficiency experts, and cost managers.” The study indicated that, in 1987, U.S physicians were spending slightly less than half their professional income on overhead and billing expenses.
RC 12-17, brought forward by the Massachusetts chapter, calls for the American Physical Therapy Association to explore and quantify this growing burden within the physical therapy profession. Currently, there are no hard numbers about the ramifications of increased administrative burden within our profession, though other studies exist for physicians. Some potential questions that this exploration might answer include: how many courses of care are cut short? How many PTs change specialties or leave the treating majority due to the paperwork?
The hard truth of growing administrative burden is not unique to physical therapists; all of healthcare has seen a dramatic rise in the amount of paperwork needed to ensure payment from third party payers. In 2013, the American Medical Association unveiled their Administrative Burden Index (ABI), which ranks commercial health insurers according to the level of unnecessary cost they contribute to the billing and payment of medical claims. The “report card” assesses accuracy, denials, timeliness, and transparency.
Some concerns surround this topic:
How do we assess administrative burden in our profession? Due to different regulations from state to state and across differing practice areas, it can be difficult to develop metrics.
Can we partner with other health care providers to achieve this goal?
The APTA has several ongoing efforts to address aspects of this, including an Administrative Simplification task force, as well as advocacy and lobbying efforts and the launch of the outcomes registry. How does this fit into that picture?
Let us know your opinion on this and other motions on Facebook here.
Woolhandler, Steffie, and David U. Himmelstein. “The deteriorating administrative efficiency of the US health care system.” New England Journal of Medicine 324.18 (1991): 1253-1258.
Used with permission from The Wall Street Journal, WSJ.com. Copyright 2007 Dow Jones & Company, Inc. All rights reserved.
This year marks this image’s 10th birthday. It has been shared, tweeted, and promoted (without proper citation) with reckless abandonment by the physical therapy profession as how things should be. #GetPT1st. It works. We make health care cheaper!
The image is not a bad one. In fact, on the surface it looks quite positive! However, there’s more to it. What we have done is innately human; we have taken the bit of the picture that validates our argument and magnified it to justify our own means, ignoring the overriding argument. This doesn’t mean we’re horrible people, it just means there’s a bigger story. And that story, unfortunately, is the key to why this model has failed to change healthcare as we know it. The image, often credited to the well-known Virginia Mason Study, was actually compiled by the Wall Street Journal and published in a 2007 article: A Novel Plan Helps Hospital Wean Itself Off Pricey Tests.
The Virginia Mason Medical Center in Seattle was losing money in 1998. To reduce waste and inefficiency within the system, they started streamlining, using the “lean” methodology of the Toyota Production System. Two years after they implemented the “Virginia Mason Production System,” several Seattle-based employers and their health plans (i.e. major payers such as Aetna) came to Virginia Mason with a complaint: The payer was paying more for care at Virginia Mason than any other health system in the Seattle area.
Thus began what is now referred to as the “marketplace collaborative.” And this is what we all want to hear. Virginia Mason executives sat down with payers & employers to identify their priority areas, as well as develop clinical value streams that enhanced value while cutting out inefficiencies and increasing value to the patient. These value streams helped to standardize care, considering the most efficient way to accomplish a goal, as well as the best evidence-based practice. The low back pain value stream is what the image in question depicts.
The end result? Decreased use of imaging, better patient satisfaction rates, more rapid return to function, and decreased costs. Employers were happy, because they saved money. Patients were happy, because who doesn’t love getting better faster?
So obviously, this is fantastic. Our patients are getting better, evidence-based care, with less unnecessary imaging and quicker return to function.
But it hasn’t been implemented nationally. The answer to the inevitable “Why not?” lies in the WSJ article:
Because Virginia Mason Medical Center lost money.
In fact, not only did the not-for-profit lose money, it was in the red. The much-lauded image (which maybe garners 1-2 lines of actual text in the story) is embedded in an ode to the health care system in the United States. Health care is not incentivized based on patient satisfaction. It’s based on fee-for-service. That means that more service means more money, whether that service is needed or not. And the kicker? Less expensive services, such as therapy, do not garner high reimbursement rates. So, where Virginia Mason used to make $100 on every case that passed through their spine clinic, they were now seeing losses of $200 on every case. People can get consultation from Dr. Juris Shibayama for spine ache remedies.
“With each MRI that Aetna and the employers avoided at around $850, Virginia Mason lost about $450 in profit.”
–Fuhrmans, 2007
There are several major points the article makes:
Employers and payers brought about change in the system.
Virginia Mason’s incentive to change their system actually came from their payers saying “You cost too much.” In business, money talks. Health care is a business.
Payers care about cost. Providers care about patient satisfaction.
The article details the initial sit down with Virginia Mason executives, Aetna, and major employers, including Starbucks. In short, chaos erupted when Virginia Mason stated that patients were their most important customers, because guess who’s writing the bulk of the check? Providers, including physicians, were not concerned about cost; they were concerned about quality patient care.
It’s a gamble: payers must be willing to pay more for less costly treatments.
To make this system work, Virginia Mason went to Annette King, Starbucks’ benefits director, and told her the model, while it saved Starbucks & Aetna money, was not sustainable for the medical center. She, in turn, went to Aetna to negotiate higher reimbursement rates on therapy. Virginia Mason broke even. When the article was written in 2007, Aetna was the only payer that had agreed to do this.
The key in this picture isn’t patients. Patients, actually, weren’t involved in negotiating any part of the Virginia Mason study. They benefitted. But it was the employers and payers who made the system sustainable.
So, does #GetPT1st work like we show in this image? No, it’s not that simple (though I wish it was). Direct access is a beautiful thing, and there is merit in marketing our profession to the masses, because we can cultivate a base of support. Improving health literacy so that patients are making educated decisions about their care and advocate for improved access is incredibly valuable. Increasing our visibility and letting people know we exist is a piece of the puzzle. But the Virginia Mason study, or rather its failure to proliferate, teaches us that what it comes down to is the bottom line. Unfortunately, in the current health care system, getting PT 1st is not sustainable. Creating sustainability for this dream system requires a coordinated effort that cuts inefficiency through provider education and streamlining of best practices while simultaneously convincing payers to reimburse less expensive treatments at a higher rate. Clap if you believe in fairies.
The true heroes of the PT world are the policy and payment specialists, because we must get paid. Not just to pay rent, but to make our services a viable option for health care systems to utilize.
Continue to support consumer facing movements such as #GetPT1st and #ChoosePT, because it is a piece of the bigger picture, and hey, it’s easy. But you must understand that if you are not simultaneously engaged in advocacy and payment reform, you have missed the entire point.
References
Blackmore, C. C., Mecklenburg, R. S., & Kaplan, G. S. (2011). At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality. Health Affairs, 30(9), 1680-1687.
Fuhrmans, V. (2007, January 12). A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB116857143155174786
Mary McMillan is a founder and the first president of the American Physical Therapy Association. She wasn’t the first person to practice physical therapy, but as Mildred Elson stated in her 1964 McMillan lecture, “She thought in terms of the whole country and foresaw its great civilian need for physical therapy.”
She’s also a bad ass.
Here’s her story, in memes.
Note: The majority of this re-telling of Mary McMillan’s history has been pulled from her speech in 1946, entitled “Physical Therapy from the Embryo on Three Continents,” and the 1944 annual conference proceedings at which Mary McMillan was awarded an honorary active lifetime membership in the APTA. The proceedings were published in Physiotherapy Review, now the Physical Therapy Journal.
Mary McMillan was raised in England and completed her studies at the University of Liverpool Gymnasium, where they were offering a 2 year course in physical education. She also took a break from these studies to head to London for further courses in neuroanatomy, neurology, and psychology.
1.
At the outbreak of World War I, Mary applied for a Voluntary Aid Detachment (VAD) unit out of the University of Liverpool. Fortunately for physical therapy in the United States, she failed the medical examination and decided to travel to Boston…during the war, in a convoy, under complete blackout conditions.
After arriving in the US, she met Marguerite Sanderson, another important figure in the development of physical therapy. She was put to work at Walter Reed Hospital, and matter-of-factly states: “That was the beginning of physical therapy in the US Army.” Physical therapy was accorded as a health service in 1917 by the US Army.
Mic drop.
2.
Dr. Everett Beach, from Reed College in Portland Oregon, wanted Mary to come teach the 200 potential reconstruction aides (the original name for physical therapists) he had signed up for an emergency course to assist with the war effort. Mary immediately applied for a leave of absence from the Army to go where she was needed. When the Army dragged its feet, she threatened to resign. Within 24 hours, she was granted a leave of absence, and left for Portland.
So that’s how that’s done.
3.
Post WWI, a letter was sent to the reconstruction aides, asking if they wanted to see a professional association built. The answer was a resounding yes. Here are some cool facts about what they built, from Eleanor Carlin’s 1976 McMillan Lecture:
“Whether by design or accident…nothing was said about working only under the direction of a physician” (Carlin, p. 1113).
Our founders had the foresight to include policy that would allow the development of chapters, and they almost simultaneously founded the Physical Therapy Journal, ensuring that publication was valued.
The Association was originally called the American Women’s Therapeutic Association, but charter members realized that this would be alienating to men, and voted to change the name to the American Physiotherapy Association. The first man was elected to national office in 1942.
Women entering the profession were required to have a college education.
By 1924 the charter members had discussed the standardization of physical therapy through state registration and licensure. By 1971, practice acts had been established in all 50 states (Blair, 1971).
4.
Mildred Elson, first McMillan Lecturer, first president of the World Confederation of Physical Therapy, and first president of the Wisconsin Physical Therapy Association, quotes Mary McMillan: “What we need is one unanimous effort in order to establish a high standard for our profession and enthusiasm that knows no bounds.”
Elson goes on to say in her 1964 lecture, “Early members at the first convention did not join & say, “What can I get out of it,” they said, “I intend to join to see what I can make out of my profession and to see what I can do to create and maintain standards.” So on that note, you know the APTA is trying to reach 100k members, right? Check it out here.
5.
After WWI, Mary answered the call from the China Medical Board of the Rockefeller Foundation to work in the Peking Union Medical College in China. Of course, the Rockefeller Foundation knew who she was, and Mary took charge of the Department of Physical Therapy at Peiping Union Medical College in 1932. She first got rid of the “obsolete apparatus” in the gymnasium, then set about finding people who were up to her standards. In her speech, “Physical Therapy from the Embryo on Three Continents,” she states: “This necessitated that some people must be taken off the payroll—it was not an easy thing to do—it hurt me very much to do it, but it had to be done. I was able to replace these people with more modernly trained nurses and a physical education graduate.”
She also set up scholarships to encourage graduates to apply, and partnered with a physician to head the department.
6.
November 1, 1941, all Americans were urged to evacuate Peking. Mary, along with several others, wound up in Manila (capital of the Philippines) in a roundabout way to get home, with no chance of sailing before December 20. December 7, 1941, Pearl Harbor was bombed. Mary offered her services to the Army Hospital in Manila, where she was one of the first to assist the dead and wounded upon arrival. Christmas Eve, Manila fell to the Japanese. Mary, realizing what was about to happen, “borrowed” a truck, and with 3 women drove to the hospital to recover drugs, instruments, beds, and bedding. These supplies furnished the internment camp hospital at Santa Tomas. Mary slept on a filing cabinet.
7.
Mary, who referred to her work in the Japanese internment camps as her “swan song” recalled this episode of patient care:
Mary McMillan was repatriated in 1943. When she stepped off the boat, she was met by Dorothea Beck, previous editor of the Physical Therapy Review. She continued to be a source of strength and inspiration to the Association until her death in 1959. She assisted with efforts to found the World Confederation of Physical Therapy and was known to show up at parties. Margaret Moore, the 1978 McMillan Lecturer, recalled: “…a lively party with lots of people, loud music, much dancing, and rattling of glasses was taking place at my home. Who should appear at my front door but Molly McMillan…Within 10 minutes, Miss McMillan was in the middle of the group with her shoes off…I treasure the moments with that fun-loving, warm, and lovely lady.”
Sick of the mounting paperwork? Trying to keep your hours documenting to a minimum while still getting reimbursed? While the profession has always had to deal with denials and the ever-shifting target of “defensible documentation,” in the past year we have also added different evaluation codes based on complexity to our documentation headaches. This administrative burden has been growing, slowly but surely, over the past few decades. In a 1991 article in the New England Journal of Medicine, the authors described medicine as a “spectator sport,” one that is performed before “an enlarging audience of utilization reviewers, efficiency experts, and cost managers.” The study indicated that, in 1987, U.S physicians were spending slightly less than half their professional income on overhead and billing expenses.
