I’m presently completing day one of “shelter at home” courtesy of COVID-19. As I am a regular worker from home, some parts of my day has not changed. Others, have changed greatly, and, really, who knows what is to come. I translate all this to: it’s a fine time to start writing again. Thus, new theme, new look, new images, and new thoughts for everyone!
WebPT’s 4th annual Ascend Conference took place in Washington, D.C. the weekend of September 29th. Rehab therapists from around the world attended business discussions on increasing revenue, outcomes, payment reform, Medicare audits, healthcare, and much more. There was SO much to learn over two full days. If you didn’t get a chance to attend, you can still benefit from the great material presented! Check out my main take away points below!
Be where your feet are
Whether you’re at home, work, lunch, or meeting someone for the first time, give him or her your utmost attention. We live in a world where distractions are everywhere. It’s not uncommon today to see two people dining together while staring at their phones instead of engaging in each other. This breaks my heart.
Alan Stein Jr. hit this point home during the keynote address day 1 at WebPT’s Ascend Event. He emphasized giving everyone in your life your full attention while focusing on the things and people that make you the happiest throughout your day. It’s so easy to lose sight of what we cherish most in life. I challenge you to put your phone down, worry less, listen more, and be where your feet are.
Outcomes, outcomes, outcomes
Healthcare, as we know it today, is changing. We’re moving from a fee-for-service system to a value-based care system. So what does that mean? Currently, clinics get paid based off of the services they provide. $100 for an eval, $10 for a modality, whatever it may be. By 2019 this could be something of the past for Medicare payment. The Merit-Based Payment System or MIPS will provide payment based on quality and performance in the clinic. How can that be measured? OUTCOMES. MIPS will account for plus or minus 9% of your Medicare payments. Losing 9% for low performance on outcomes is a BIG deal. Check out my interview on the matter with CEO of WebPT, Nancy Ham. How can you lessen the stress of the payment reform? Prepare.
Prepare for Payment Reform
Start now by using data-driven outcomes. Measure not only outcomes but also patient satisfaction. One of the biggest questions during the discussion on outcomes was, “What about non-compliance?” It’s not always easy to have a patient complete their plan of care and that can lead to loss of success with outcomes. Practice owners Mike Mundry and Mike Manzo gave great advice on how to increase participation in patient-reported outcome measures. When determining patient satisfaction, consider emailing the report straight from the clinician. Patients are more likely to open and respond when they know it came straight from their provider. Why not give a paper report in the clinic? This can skew results. If a clinician hands you a satisfaction survey and stands over you smiling would you be honest with your report? I’d feel pretty pressured. Accuracy is key.
What about those patients who never show up for a formal discharge? This is tricky. Try contacting the patient through multiple routes. Give a phone call and ask them to come in for one more visit and a new HEP, email the outcome directly, consider mailing the outcome to patients who might not use the computer as often. Start practicing these measures now and determine your faults and successes before the payment reform begins. Refine your skills, try different outcome measures, find what works best for you now so you don’t have to panic later when change comes.
CPT Codes are important
As you know, new CPT codes came out this year. CMS projected that initial evaluation complexity codes would add up to 25% low complexity, 50% moderate complexity, and 25% high complexity. WebPT researched their data from the first 6 months of the year to see if those projections are in alignment with what we’re seeing in the clinic. Guess what? They’re not. After collecting over 500,000 initial evaluation CPT codes reported, WebPT determined the rehab industry is actually submitting around 45% low complexity, 45% moderate complexity, and only 10% high complexity. What does this mean? As of right now, these complexities don’t reimburse differently, BUT one day they could.
Rick Gawenda, PT emphasized the importance of choosing the correct CPT code for your evaluation. Professionals need to report accurately because in the future each code could come with a dollar amount. Let’s say you’re choosing the low complexity CPT code for every evaluation because, right now, it doesn’t affect how much you’re getting paid. Then, CMS comes out and decides to pay a certain percentage more for high complexity and less for low complexity. If you start increasing your evaluation codes to higher complexities compared to what was first projected, you could be looking at a Medicare audit. Learn the identifiers for each complexity, choose accurately, avoid the audit.
Check out the Talus Media Talks interview with Nancy Ham, CEO of WebPT:
Addiction is a disease that disregards an individual’s race, socioeconomic status, and prior achievements. Since 1999, deaths from prescription opioids have more than quadrupled. From 1999-2010, the number of prescription opioids sold to pharmacies, hospitals and doctors’ offices has nearly quadrupled as well. Yet the amount of pain Americans report has not changed during this time.1 In 2012, health care providers wrote 259 million prescriptions for painkillers. That is enough for every American adult to have their own bottle of pills.2
I was lucky to get the opportunity to speak with former NFL offensive lineman Jeff Hatch. Throughout his life, Jeff did everything the “right” way. He won the Presidential Award for his work with the homeless, graduated from the University of Pennsylvania, where he became unanimous first team All-Ivy selection and Division I-AA All-American, dated Miss Maryland, and signed a multi-year $1 million contract with the New York Giants – all by the age of 22. However, Jeff was not happy. According to him, checking off all of his accomplishments was a way to disguise his contempt for himself:
I was determined to be successful as I could be… On one hand, doing everything well enough could make me happy and on the other hand doing things well… would keep people from looking too deeply into what was going on with me… It was a way I could mascaraed and keep people at bay
This contempt, in addition to a family history of substance misuse disorder, fostered Jeff’s relationship with substances. The first time Jeff was exposed to opioids was following his career-ending spinal fusion surgery. He recalls the opioids working great to relieve his physical pain, but it wasn’t long before he was utilizing the pills to resolve the emotional pain he was dealing with.
People say [substance abuse] is a slippery slope that you go down. For me it wasn’t a slope, it was a cliff and I jumped off
Opioids and alcohol gave Jeff something that all his past achievements did not fulfill. It allowed him to be comfortable in his own skin. He shares how drug and/or alcohol consumption is different for someone affected by substance misuse disorder: “I think there’s a difference between somebody who suffers from the disease of addiction and somebody who can participate in using drugs or alcohol recreationally and not have a problem. For those of us who suffer from the disease, the use of drugs or alcohol is a tool by which we escape our reality, not a means by which we seek a good time.”
Jeff was fortunate to receive treatment in 2006 and has now been sober for over a decade. Though he continues to experience pain from a physically taxing football career, he believes exercise and NSAIDs are powerful analgesics that are often overlooked in the management of chronic pain.
Not only has Jeff successfully battled this disease, but he also uses his personal story and experiences to inspire others to seek and remain committed to recovery. Jeff works for Granite Recovery Centers, a New Hampshire based substance misuse disorder treatment provider. This comprehensive program treats individuals throughout all phases of recovery. The program focuses on the 12 steps then offers a bridge program, The Granite House, that continues to work on life skills necessary for community re-integration. Although getting quality treatment is a staple for those in recovery, Jeff states there are additional factors that need to be addressed to successfully combat the epidemic.
We need to continue to break the stigma down, we need to continue to fight against the insurance industry and them trying to close the portals by which people use to get treatment and we need to continue lobbying the government to treat this disease the way it needs to be and to really follow through with that Parity Act that got signed in 2008
Though it is easy to get caught up in the statistics surrounding the current state of the opioid crisis, Jeff explains how we should look at the glass as half full: “We look at the 23 million people suffering from substance misuse disorder in America and we go ‘Oh my God what a terrible problem’ but on the other hand there are 24 million people who are in long term recovery from it and we don’t ever really talk about that.”
The Journal of Orthopedic and Sports Physical Therapy (JOSPT) recently released a special issue on the topic of whiplash-associated disorders (WAD). This July 2017 publication followed up on the October 2016 issue, both with guest editors Dr. James Elliot, an associate professor at Northwestern University, and Dr. Dave Walton, an associate professor at the University of Ontario. This rare opportunity to have outside editors underscores the challenge that not only clinicians are facing when treating WAD, but the imperative need that patients with WAD struggle with on a daily basis. From an overarching perspective, the special issues highlight that WAD is not simply an orthopedic condition, yet one that encapsulates the physical, social, and cognitive aspects of the patient at hand, which works to complicate the treatment approach further.
Whiplash-associated disorders are common neck injuries, most often seen in motor vehicle accidents. In Europe and North America, WAD is seen in 300 per 100,000 individuals in an emergency room setting.1 The annual cost of personal injury claims in the United States alone is estimated to be around $230 billion.1 In addition, consistent international data suggests that approximately 50% of those who sustain a whiplash injury will actually not recover and continue to report ongoing pain and associated disability one year after the injury.1 This low rate of improvement underscores the idea that whiplash has other psychosocial components. A 2014 article in the Journal of Physiotherapy discuss that of those who have sustained a whiplash injury, many concurrently are affected by mental health concerns, as well. 25% of those with WAD have post-traumatic stress disorder, 31% have a “major depressive episode,” and 20% have generalized anxiety disorder.1 This combined psychiatric involvement leads to poorer outcomes, secondary to the elevated levels of disability, chronic pain, and physical activity that these patients have.
Talus Media’s Eric Robertson had the opportunity to interview Elliot and Walton recently to discuss the special issues, as well as the current landscape of WAD in a physical therapy setting. The conversation discussed many components of WAD, including the approach that clinicians take when treating patients. Elliot stated that:
“Considering whiplash as a homogenous type condition and treating it as a homogenous condition is really at the crux of really why we haven’t seen fantastic results of management strategies.”
The two also argued that therapists should not be looking at whiplash from a biomechanical or tissue-focused perspective, “It might be more valuable to take an approach that moves away from the tissue at fault, because so far that has proven to be a fool’s game, and move more toward the question of ‘what is the likelihood the patient is going to get better.'” Elliot and Walton did, however, state that they do believe there may be the involvement of some specific tissues in the body. “We do have some fairly compelling evidence that it looks like in some discrete number of people with chronic problems that their white matter in their cord may have been damaged or certainly involved in some of these changes in muscle structure and function.”
The two JOSPT special issues are available online from both October 2016 and July 2017. In addition, the full interview with Dr. Elliot and Dr. Walton is available on Talus Media Talks. What is your experience in treating WAD? Do you feel as if there is something missing in the treatment of these patients? Let us know what you think on our Facebook page.
Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother. 2014; 60(1):5-12.
Back in February at the Combined Sections Meeting, the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) announced their new quality standards for post-graduate education. The release of the new standards marked ABPTRFE’s first step towards its initiative of revamping old policies and procedures. According to Tamara (Tammy) Burlis, Chair of ABPTRFE, the intent is to“ultimately enhance patient care and support overall goals of the physical therapy profession”. An external consultant company specializing in accreditation and compliance solutions for higher education helped with the development of the new standards. After a 6-month call for comments, the standards were finalized and are now slated to take effect on January 1, 2018. Residency and fellowship programs have until January 1, 2019 to comply. Physical therapy news outlet Talus Media News featured this story in their August 14th episode.
Behind the buzz of the shiny new standards, however, is the discontent expressed by some fellowship directors. The biggest concern regards the change in admission criteria into fellowship programs. Historically, there were three ways to be considered for admission into fellowship: (1) complete an accredited residency, (2) earn board certification in a related field, or (3) have adequate prior experience as judged by the program directors. The new standards have removed the third option, leaving residency training or board certification a mandatory requirement prior to applying for fellowship.
Pieter Kroon, program director and co-owner of The Manual Therapy Institute (MTI), a fellowship program started in 1994 for advanced manual therapy training, spoke up in an interview on Talus Media, “I understand where [ABPTRFE] wants to go with it but…there are some nasty consequences that come with that which threaten the viability of the physical therapy manual therapy fellowship programs…We have given input, but we always have the feeling it doesn’t get listened to a whole lot at the ABPTRFE level.” According to Pieter, fellowship directors don’t seem to have much of a voice in the decision-making process at ABPTRFE. The way in which program directors currently share their concerns is akin to a bad game of telephone. The manual therapy fellowship program directors share their thoughts in their Special Interest Group (SIG) meetings. SIG representatives then report to the Board of Directors at the American Academy of Orthopedic Manual Physical Therapy (AAOMPT). After that, it is AAOMPT’s responsibility to talk to ABPTRFE and pass the messages along. It’s not hard to imagine why Pieter describes the communication between program directors and ABPTRFE “tenuous at best”. Of note, AAOMPT declined to comment on the potential impact of the new standards.
The consequences Pieter referred to are a few in number, but of primary concern to fellowship programs is sustainability. Or, as Pieter more bluntly puts it: “we would be out of business”. To illustrate his point, 95% of the fellows that graduated from MTI in the past five years were admitted via review of prior experience, the route now deemed obsolete. Without such a large section of the cohort, his program would not have had enough overhead to be self-sustaining. Pieter shared off record that he runs his program because he loves teaching and helping clinicians become their best; the revenue the program generates is marginal. The new standards pose a big bottleneck to fellowship admissions, limits student accessibility, and places programs like his on a pathway to an uncertain future.
But what makes fellowship programs think they won’t get enough applicants?
Though there has been a paradigm shift in recent years where clinicians are looking towards residency training soon after entering the work force, there has yet to be an identifiable fiscal incentive for clinicians to become experts in the field given their low ceiling of professional compensation. Furthermore, time is of the essence. The American Board of Physical Therapy Specialties currently only offers certification exams once a year. So, not only are the additional certification exams expensive, it also requires foresight and planning to fit it into one’s professional and personal timelines. There is additionally a current lack of evidence that suggests being a resident-trained therapist and/or having board certification contributes to being a more prepared fellow. Though that’s not to say there won’t be evidence of this in the future, it does call into question how this new admission standard was arrived at. Did it consider any of the current evidence in post-graduate education? Or, was it developed with more philosophical underpinnings? To that end, it remains to be seen…
PT Think Tank community: the point of this piece isn’t to say that the new admission standards are “bad”. Rather, I hope it makes us consider how its proposal potentially overlooks the current reality of the residency/fellowship climate. What parameters are in place, if at all, to help address the worries of Pieter and other program directors? What will be in place to aid them during this period of transition?
I’ll end it here, but do think on this last part of ABPTRFE’s position on the new admissions criteria: “Our goal is to support residency and fellowship programs, while addressing and planning for the future…As a part of our own continuous improvement process, we will continue to monitor the data that occurs as a result of this revised change. We will go back to this concept if we find that it has been detrimental to fellowship programs.”
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.
Has it ever seemed like there are a lot of white people in Physical Therapy? Yeah, it’s not just your imagination.
This is the APTA. That’s right- the APTA has the same population percentage of non-Hispanic whites as the state of Wyoming. APTA member data from 2015, indicate only 15.5% of members were of a minority race or ethnicity. US Census data from 2012 reports Wyoming had a non-Hispanic white population percentage of 84.6%. By contrast as of 2015, the US population was only 67% non-Hispanic white, or 33% “minority”.
Limited professional diversity in PT has not only been a persistent issue but an issue that by many metrics is getting worse. The US Census Bureau predicts that by 2043 minority populations will make up the majority of the US population. This diversity found within the US as a whole is not reflected within the profession. For example in 2010 Hispanic/Latinos made up 16.3% of the US population but in 2014 only 6.2% of PTCAS applicants accepted. Black/African Americans represent 13% of the US population but only 2.7% of accepted applicants through PTCAS. For all APTA members, only 3.7% are Hispanic/Latino and 2.6% black/ African Americans. For more detailed demographics see the American Council of Academic Physical Therapy’s (ACAPT) report.
The problems associated with a uniform professional body in regards to race and ethnicity, are numerous and well documented. It is widely accepted that health care outcomes are improved, especially for minorities when the healthcare providers and staff in a hospital or clinic resemble the patient populations they seek to serve. One frequently cited consequence of inadequate minority representation within the healthcare professions is reduced utilization of preventative care and increased utilization of emergency services.
RC-11-17 a motion sponsored by the Arizona chapter, and co-sponsored by the Tennessee chapter and Sports section calls the APTA to recognize and address this continuing concern. The motion states:
That, by June 2018, the American Physical Therapy Association, in collaboration with relevant stakeholders, identify and begin to implement best practice strategies to advance diversity and inclusion within the profession of physical therapy
Two linked, yet separate concepts, diversity and inclusion are called to the attention of the profession. Diversity, the “range of human differences, including but not limited to race, ethnicity, gender, gender identity, sexual orientation, age, social class, physical ability or attributes, religious or ethical values system, national origin, and political beliefs”. Inclusion is “involvement and empowerment, where the inherent worth and dignity of all people are recognized”.
The PT profession at present is not diverse. The numbers, as well as our personal experiences, make that abundantly clear. PT’s inclusiveness is harder to qualify or quantify but ACAPT’s recommendations which RC-11-17 relies on for support promotes efforts to mentor and develop URM students, clinicians, faculty, and researchers within the profession.
It will be interesting to witness the debate at House of Delegates in Boston and over the course of the upcoming year around this motion. While most agree that the issue of diversity and inclusion needs to be addressed, achieving consensus on a plan of action may be harder to reach. A good starting point would be greater understanding the factors and causes of the lack of diversity within the profession. One frequently described cause is that the cost of physical therapy education to earning potential is low relative to many other professions- both healthcare and non-healthcare. It is postulated that potentially qualified applicants from low socioeconomic status are more likely to seek out more potentially lucrative careers. ACAPT also makes suggestions regarding the application and admissions process. Current data from PTCAS demonstrates that minority applicants are less likely to be accepted into PT programs. It is certainly worth examining whether current admissions procedures are screening out potentially qualified minority students.
Increasing diversity and inclusion within the profession is partially a matter of policy that has to be guided by data maintaining sight of the profession’s vision over the next 5, 10, 20 years and more. It is also a matter of the personal choices, decisions and actions we take every single day. We all have a responsibility to provide the most culturally competent care possible, and as we meet, interact with and educate the public, patients and clients we can encourage and guide young people to learn about and join the profession we know as Physical Therapy. Please let us know your opinion on this and other motions and follow us on Facebook here.
As we continue to explore the motions at the 2017 American Physical Therapy Association’s House of Delegates, RC-8-17 plans to stir some discussion. The motion reads and charges, “[That] the American Physical Therapy Association develop an external entity to expedite the creation and growth of effective transformational innovations that revolutionize physical therapist practice and positively impact society.”
Our vision statement, “Transforming society by optimizing movement to improve the human experience,” makes it clear that we as a profession will be able to improve the human movement of enough individuals to create a societal change. As therapists across the country interact and improve the movement of the members of society the questions remains, are there enough of those interactions taking place that cross the threshold necessary to transform society? Will a bottom-up approach alone create that societal change, or do we also need a top-down approach and guidance for the association to ensure that the bottom-up approach is united and effective in its effort?
The makers of this motion believe that “physical therapists do not appear to have the tools and/or models to transform society given the numbers of individuals required to actually have a transformative effect.” As a result, this motion calls for the creation of a separate external entity much like The Foundation For Physical Therapy. This entity would be modelled similarly after the American Medical Association’s Innovation Ecosystem, which brings diverse experts together to improve physicians’ processes and therefore patient care and outcomes. The external entity of RC 8-17 would be focused on “proving market effectiveness, thereby bringing transformative and scalable innovations, operated by practicing physical therapists, into the market at large.”
While healthcare is a rapidly changing environment, turning to our colleagues from other professions may serve as inspiration to help the profession of physical therapy adapt to the dynamic world of healthcare effectively. Nonetheless, last year the APTA established a council to stay up to date with the changes of healthcare called the Frontiers in Research, Science, and Technology (FiRST) Council, which looks to advance science and innovation that our profession needs to understand and incorporate into our practice, education, and research. Yet, there seems to be no mention of how this council would impact and achieve transforming society.
What seems to be the most difficult portion of this motion is the lack of detail that would describe how it would work, how it would operate, and to what extent the financial expectations of APTA would be. Please let us know your opinion on this and other motions and follow us on Facebook here.
Motion RC 7-17 proposed by the Georgia chapter would support efforts of residency and fellowship programs accredited by the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFRE) to encourage program participants to be members of both the APTA and their associated specialty section. The ABPTRFE is a department of the APTA. This department is funded by the APTA and subsidized by fees from accreditation, re-accreditation, applications, etc. At the moment, the American Academy of Orthopaedic Manual Physical Therapist (AAOMPT) fellowships strongly encourage APTA membership according to the AAOMPT 2011 Education standards. However, this one class of Fellows in Training (FiT’s) only account for a small percentage of all ABPTRFE accredited programs.
Currently, a policy mandating APTA and section membership is at the discretion of each individual program. This motion would not require those pursuing a residency or fellowship to become members, rather it allows the APTA to take a position supporting the efforts of programs to encourage membership. Physical therapy residents have a set of Core Competencies structured as a means to evaluate participant’s success in the program. The Professionalism core competency is defined as:
Conducts self in a manner consistent with the APTA Code of Ethics, inclusive of the Core Values, in all professional responsibilities and roles.
As members of the APTA, residents and fellows inherently meet many of these Core Competencies and gain access to resources that can contribute to their professional development.
Although this motion is a great step in supporting the association that protects and provides for our profession, does it go far enough? Would mandating membership on post-professionals increase animosity towards the APTA and decrease opportunities for one to develop a perceived value of membership? Does one engage more with the benefits of membership when joining voluntarily? The APTA’s ultimate goal is to gain members who value their membership.
In terms of mandating a membership for any or all segments of PTs, the proposal would be a daunting task. Mandatory membership would have to be pursued on a state-by-state basis, which raises the dilemma of who would be responsible for verifying one’s membership status. Suppose membership was tied to licensure, The Federation of State Boards of Physical Therapy (FSBPT) would experience a massive increase in administrative burden that wouldn’t necessarily increase the safety and/or competence of the PTs they are certifying.
Let’s set aside all the logistical and perhaps ethical issues surrounding a mandatory membership for residents and fellows and take a look at the numbers. Below is a table adapted from the “Minimum Eligibility Requirements and General Information for All Physical Therapist Specialist Certification Examinations”:
Application Review Fee
As of 2007, the House recognized residents and fellows enrolled in an ABPTRFRE-credentialed program as a “Post-professional Student Member” with associated national dues of $150. However, even prior to this designation, it would still be financially irresponsible to pay over $1,000 more as a non-APTA member to obtain a clinical specialty. Regardless of your position in terms of how much you value APTA membership, the educational, as well as financial benefits of an APTA membership for residents and fellows, are tough to dispute. Please let us know your opinion on this and other motions and follow us on Facebook here.