4 Take Home Points from Ascend 2017

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.

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. If you are stressed or anxious, buying delta 8 THC gummies online from a reputed store will be a great help.

Prepare for Payment Reform

Discussing 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:

2017 House of Delegates Preview: Lifecycle of a Motion

PT Think Tank is proud to announce that over the coming weeks leading up to the NEXT Conference and the annual House of Delegates meeting, we will be covering all proposed motions in detail. These motions by nature are complex and have taken enormous amounts of effort and time from the authors and the Reference Committee to compile. Our goal is to provide insight and high-quality background information to these motions and begin a conversation about how these motions if accepted, could change our everyday practice of Physical Therapy. In order to effectively understand the motions that are being presented for the 2017 HOD, we must first understand how motions are developed, organized, and presented.

According to the APTA, all motions other than bylaw amendments, serve one of four major purposes. They define a course of action (policy), a stance (position), a binding statement to judge the quality of action (standards), or clearly state a goal the APTA wishes to achieve. Motions are vetted, researched, and revised over the course of a one or two year cycle, which typically revolves around the HOD meeting at APTA Next in June. Some more complex motions may take up to 2 years of research and refinement prior to being introduced to the House. The APTA has identified 3 major phases of the motion lifespan: Conception, Development, and Presentation.

Lifecycle of a Motion Infographic

So what does the Reference Committee do, and how many motions are introduced every year? According to Dr. Michael Pagliarulo, PT, MA, EdD, Member and former Chair of the RC, roughly 20-30 motions come before the HOD each year, but that number is decreasing as a result of considering issues of more significant impact on the profession and society.  The RC’s job is not to research these motions, but to assist the delegates in the motion development process. They provide advice and counsel to the delegates on form, wording, and method of motion presentation – helping the delegates clearly state motion’s intent. This is a complex process and the RC provides the guidance necessary to the authors so it can run as smoothly as possible. And running smoothly is extremely important in this process, as Dr. Pagliarulo explains what happens once the motion is moved:

“Once motions are moved, seconded, and announced by the speaker, they become the property of the voting body. That body then debates that motion and can then vote to adopt or defeat.  Amendments are also in order during the debate.  The amendment can also be amended.  Then you must go backwards to vote on the amendments.  Once they are dispensed, other amendments are in order, and they must be voted on.  Once the body has exhausted amending the main motion, then the main motion is voted on as amended, if any of them had been adopted.  To make matters even more exciting, there are other types of motions that could occur during the debate. For example, the motion could be referred to the Board of Directors for further consideration, or postponed definitely to be considered after interested parties had an opportunity to meet and reach consensus on issues, or postponed indefinitely, which essentially defeats the motion.  There are even other types of motions, but these are the main ones. This is why we always have a parliamentarian present at the House to help us get through some complex strategies.”


Got it? Good! Starting May 11, we will report on each of the motions that will be coming before the HOD in June. Stay tuned!



PT Think Tank would like to sincerely thank Dr. Michael Pagliarulo for his assistance in this project.

2017 Packet I can be found here.

2017 Background Papers can be found here.

Helpful Webinars (Free to APTA members!):

Where #GetPT1st Doesn’t Work: The Bottom Line

Paths to Recovery
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.

For those unfamiliar with the Virginia Mason Study, it goes something like this (the full text is available here):

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:

  1. 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.

  1. 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.

  1. 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.


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 Affairs30(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

Priceless Protections: Pre-Existing Conditions Can Happen to You!

Well, here we are again, on the cusp of another GOP vote on health reform, and about to lose federal protection for pre-existing health conditions. Troublingly, there has been this discourse floating around that places blame on said person with a pre-existing condition. As if, by making correct decisions, you can avoid having a need for health care, therefore, you should not have to pay for someone else’s care who made bad choices. This logic largely ignore rates of obesity and heart disease correlations to states where representatives (and constituents?) seem to think this way. Well, it’s wrong. Health, or the lack of it, is not a reflection of morality, or worth. Sometimes, and I know this personally, it happens in a split second.

To illustrate this point, I’d like to share the story of a very dear friend of mine, Courtney Kelsch Ward and her family. Courtney posted this on her Facebook shortly after Jimmy Kimmel’s tale from Monday night. She was gracious enough to share. I think it illustrates the stark odds (and costs) in front of us as a nation as Congress decides to abolish pre-existing condition protection.

The Story of Baby Robbie

On Monday night, Jimmy Kimmel gave a moving monologue in which he described the gut-wrenching experience of discovering his newborn son had a heart defect. Through tears, he explained the harrowing minutes when the doctors and nurses were examining his son in the neonatal intensive care unit, the ambulance transfer to a specialized hospital, and his son’s three-hour open-heart surgery. The story had a happy ending, thankfully, but Kimmel ended his talk with a plea for compassion and reason in healthcare reform.

Before 2014,” he said, “if you were born with congenital heart disease like my son was, there was a good chance you’d never be able to get health insurance because you had a preexisting condition. You were born with a preexisting condition. And if your parents didn’t have medical insurance, you might not live long enough to even get denied because of a preexisting condition. You can contact a reliable wholesale insurance company to solve all your doubts regarding insurance and help you out. If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make. I think that’s something that, whether you’re a Republican or a Democrat or something else, we all agree on that, right?

As it turns out, we don’t all agree on that. On Tuesday afternoon, former Illinois Representative Joe Walsh tweeted,

Sorry Jimmy Kimmel: your sad story doesn’t obligate me or anybody else to pay for somebody else’s health care.

Many others echoed this sentiment. An overwhelming number of people seem to actually believe that a baby deserves to die if his parents can’t afford to save him.

Over the last nine months, I’ve had a lot of conversations with a lot of people about the state of our healthcare system, and I’ve found one assumption lies at the heart of many of these arguments—that sick people have done something wrong to deserve their fate. A few days before Kimmel’s monologue went viral, Alabama Representative Mo Brooks said that increasing costs for people with preexisting conditions will help to reduce “the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy.” These are the people, he said, “who have done things the right way,” the implication being that sick people are those who have done things the wrong way. Back in January, Pennsylvania Senator Pat Toomey compared people with preexisting conditions to burned down houses. This belief is common. Not everyone says it as explicitly as these legislators, but deep down, many people hold this view—that good, hard-working, responsible people don’t end up in these situations.

I’m here to tell you, that’s simply not true.

My husband, Mike, and I approached starting a family the same we approach everything else—thoughtfully, with long discussions about logistics and preparation. We worked and reworked our budget and moved to the suburbs so we could get more space for our money. We bought books on how to have a healthy pregnancy and baby. I scheduled a mostly pointless pre-conception appointment with my doctor and took prenatal vitamins for the recommended three months prior to trying to conceive. When we finally got that positive pregnancy test, Mike wouldn’t let me lift a finger around the house. I stopped drinking wine, of course, and coffee. I even gave up my nightly cup of chamomile tea because I couldn’t find a clear answer about whether herbal tea is safe during pregnancy. I avoided unpasteurized cheeses and deli meats. I agonized over what to have for lunch every day, as even egg salad was questionable, according to the internet, as was really any cold meat. One time I asked the people at Panera to heat up the chicken on my Caesar salad, just in case. I suffered through chronic headaches because most painkillers are considered unsafe during pregnancy. My doctor said Tylenol was ok, but I avoided it anyway because a few studies have linked it to ADHD. I even started using different skincare products after deciding between a cosmetic dermatologist or surgeon because salicylic acid is considered possibly unsafe. The amounts absorbed when washing your face are minuscule, but over and over again, I asked: why take the chance?

All of this is to say: there’s doing things the right way and then there’s going way over the top, and we were certainly in the latter category.

And yet, on July 25th, after just 22 weeks and 5 days of pregnancy, I went into labor. My doctors worked hard to stop the contractions and hold off my son’s birth, but four days later, on July 29th, my son was born at just 23 weeks and 2 days gestation. Some neonatal guidelines do not suggest intensive life saving efforts at this age. At 1 lb 5 oz and 11 inches long, Robbie was about the length of my forearm. His foot was half the size of my husband’s thumb. With severely underdeveloped lungs, he was unable to breathe on his own. A good outcome was certainly not a given. He was immediately intubated and remained on a ventilator for the first 78 days of his life. He spent over 4 months in the NICU, fighting to survive. There were many days when the doctors were not sure that he would make it. To this day, nine months after his birth, we consider it a miracle that our son is home with us.

We still don’t know why it happened. It wasn’t because of anything I did or anything I ate. It may have been because of something in my biological makeup, something that predisposes me to preterm labor. But maybe not. During my pregnancy, I had a single umbilical artery and slightly low levels of a hormone called papp-a. I would recommend you to avail therapy from http://www.swiftwatermedical.com/bioidentical-hormone-replacement-therapy/ to maintain hormone wellness. Both of these things increase the likelihood of preterm labor, but by such a small percentage that neither my OB nor the perinatal doctors were particularly worried. Neither of these factors were caused by anything I did, and the doctors said they varied not just from woman to woman, but from pregnancy to pregnancy. My OB herself told me she’d had low papp-a in her first pregnancy and completely normal levels in her second. The message from my doctors at the time was very much Do Not Panic. All of our other tests had come back good, so there was no need for alarm, they said. They planned to watch me a little more closely in the third trimester, but that was it. A second trimester delivery was not on anyone’s radar.

Since Robbie was born, we have asked why I went into preterm labor, why our son was born four months early, and we have received the same answer from every medical professional: sometimes these things just happen.
The cost of my week-long stay in the hospital was roughly $50,000. The cost of Robbie’s stay in the NICU was $1.7 million. This number does not include the costs since he has been home, the countless doctor appointments, the seven medications he was prescribed at discharge, four months of home nursing, three $3,500 shots to help protect him from RSV during cold season, or the oxygen tanks as noted by SimplyO3, currently sitting in my living room. No, that $1.7 million was just the cost of his 129 days in the NICU. It’s the cost of keeping my baby alive.

If our health insurance company had been allowed to set an annual limit to the amount they will pay for one person, Robbie probably would have hit that limit in 2016. If they were allowed to set a lifetime limit, he’d probably hit that too before long. Can you imagine looking at a nine-month-old baby and telling his parents he’d used up all of his healthcare coverage for his lifetime? We have been incredibly lucky in that Robbie is doing great and has made wonderful progress since coming home, but his prematurity puts him at a higher risk for a host of health issues, and Mike and I spend every day waiting for the other shoe to drop. The reality is, some day in the future, Robbie may very well be one of those people with preexisting conditions everyone is arguing about.

There are a lot of factors to consider regarding the economics of healthcare, and we have to continue having this complex debate. But we won’t be able to solve this issue as long as we think of sickness as something that happens to bad people who are lazy and irresponsible. When you pay for health insurance, you are not just paying for someone else’s healthcare. You are paying for the possibility that you, too, may need that care someday. Your education, your hard work, your moral superiority—none of these things can protect you from a health emergency or a chronic illness. You can do everything right and still end up in a hospital bed, or standing in a neonatal intensive care unit watching your child struggle to survive. It can happen to anyone. We could have been the spokespeople for “Doing Pregnancy Right,” and it happened to us. It can happen to you, too.

It’s all in the incentives

An incentive is something that motivates an individual to perform an action.

And, that something could be anything. Meet the omnipresent influencer of behavior. Frequently, incentive is understood to be associated with some form of monetary compensation for specific behavior. But, incentives are not merely monetary. And, they exhibit influence. Yes. Always. 100% of the time. In any environment, any scenario, any interaction, and every decision including clinical encounters. Incentives can be viewed as any tangible or intangible reinforcement, and thus influencer, of behavior. Theses “rewards” range from monetary to personal, concrete to cognitive-emotional. And interestingly, incentives still affect behavior even when individuals consciously identify and recognize their presence. They are social, contextual, or even cultural. And, they impact decisions and performance.

Incentives are present in a variety of forms and contexts. Most generally, incentives can be assessed via a variety of binary comparisons including: Explicit verses Implicit, Reward verses Punishment, Short verses Long Term, and Immediate verses Delayed. Yet, the content of incentives range from monetary to verbal, and in contexts of private and public. The environment, including people, specific location, and context of the situation, in conjunction with broader constructs such as expectation and culture also matter.

Physician’s prescribing habits are affected by pharmaceutical marketing. Prescribing is affected by the gifts, no matter how menial, of pharmaceutical companies. This effect is observed even if physicians believe the gifts have no bearing on their prescription decisions. The data and incentives lead the Office of the Inspector General to research gifts and payments that promote prescription drugs. In this instance, physicians are Prescribing Under the Influence:

This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, “Oh, what’s this cute little stuffed bear?” Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: “We’ve got such and such on the hospital’s formulary now.” Or “The new form of this drug can be given once a day instead of four times a day. The patients will love it.” It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.

Self-referral, or referral for profit, is associated with increased utilization of lab tests, imaging, and physical therapy. A meta-analysis revealed a 2.48 combined relative increased frequency of referral in refer for profit scenarios. In most cases, I truly believe physicians are not sitting in front of patients actively scheming on how to justify an imaging procedure, lab test, or referral to physical therapy in order to maximize profit. On the whole, I don’t assume the physicians in these scenarios are unethical and overtly over prescribing. But, the incentive is present, and thus behavior is altered. The evidence shows that self-referral invariably leads to higher utilization and higher costs.

What are specific incentives within the profession of physical therapy? What should be modified? Everyday outcome measures are handed to patients, clinical measurements made, and assessments written. What are patients and incentivized to say and do? Or, believe? Administrators, managers, and clinic directors in hospitals and private clinics present data to their staff. Specific metrics are identified and goals are constructed.

Recognizing the development of interaction between personal and environmental (including social, societal, cultural) influences on behavior illustrates the complexity of how, when, and why we behave in certain ways. In healthcare, the layers of systems and hierarchy of influence is complicated. Our decisions and behavior are not nearly as rationale, nor conscious, as they feel to us personally. The interplay of personal, inter-personal, and environmental influences coupled with tangible or perceived rewards influences how people act. In conjunction with individual motivation, incentives, both seen and unseen, are determinants of who will thrive in certain educational and clinical contexts. One such example is the difference between extrinsic and intrinsic motivation. What people do is just as complex as why people think they do it. And, there is a disconnect, a blind spot, between our perception of bias in ourselves verses others.

Unfortunately, incentives have unintended consequences. The cobra effect is an illustration that “incentives don’t always work out the way we expect them to.” Beyond identifying a target metric and outcome, it’s imperative to identify the actual behaviors that are desired. Sometimes a change in a specific measurement (productivity, patient report outcomes, etc) do not necessarily reflect the desired behavior changes. In particular, research investigating payment incentives and subsequent clinician behavior within healthcare illustrate tangible manifestations of “unintended consequences.”

How is the outpatient therapist incentivized if measured and assessed primarily via patient report questionnaires? How are we changing behavior in the acute care therapist by assessing them based on the number of “units” they “bill?” What about the outpatient therapist who receives a bonus based upon units billed? What if changes in the metrics we are utilizing don’t truly illustrate significant change, don’t result in the best care, and don’t reinforce ideal behavior? A health services research article on medicare payment comments:

While some payment methods may lead to excessive utilization, other payment methods may put too much pressure on cost containment and potentially lead to underprovision of resident care (Coburn et al. 1993; Cohen and Spector 1996; Murtaugh et al. 1988)

In addition to tracking specific measures, ideal behaviors need to be identified. To account for unintended consequences broadly identify various behaviors likely to lead to the measured goals. Sometimes behaviors that are actually not desired can cause significant desirable change in target measures. Undesirable action for desired outcome. So, what behaviors can cause a change in the metric? And, what contributes to encouraging such behaviors? But, also, what incentivizes behaviors that change the metric, but may also cause unintended consequences?

If a clinic, hospital, profession, or health care system seeks to fundamentally alter care delivery robust assessment of the current incentives within healthcare, including conflicts of interest is mandatory. Then change the incentives to affect and encourage ideal clinician behavior. A successful approach likely involves a combination of incentivizing important outcomes as well as specific behaviors. Changing the single data point does not necessarily reflect the desired overall change in other measurements or behavior. The depth of affect of incentives in conjunction with unintended consequences illustrate the difficulty in controlling change. A seemingly brilliant idea such as “pay for performance” or outcomes based payment is fatally flawed without a conscientious focus on the many potential behaviors that may result in the specific outcome. Might it even be chaos?

What are the incentives? Identify the answers and then target behaviors requiring alteration. Shift behaviors towards ideal processes. Ideal behaviors will likely have positive unintended consequences. A myopic focus on only the desired numeric change will produce a myriad of potentially paths to “success.” Some of these paths were never the intended action of success. And in fact, may be the opposite of the incentive’s initial philosophical goal.

MedPAC Doubles Down

dice image

In theory, the Medicare Payment Advisory Commission (MedPAC) advises Congress on the best actions to take to ensure both the long term survival of the Medicare program, and that health care needs are met for Medicare beneficiaries. This is a tough task, as tipping too far to one side or another can result in wildly out of control costs, or decisions that harm the public health overall. It’s a tough assignment for MedPAC. Some decisions have been good, such as the overall shift to quality-based reimbursements. Others, like the arbitrary cap on physical therapy services haven’t been so smart. The cap limit has required action by Congress on an annual basis for over a decade to ensure there is an exceptions process.

MedPAC released their report to Congress this month. You can find the June 2013 report here. In the report, there are two recommendations suggested that negatively impact patients with Medicare through burdens placed on physical therapy providers. First, the cap limit has been recommended to be reduced from $1900 per year to $1200 per year. Remember, this is a cap that is shared with Speech and Language Pathologists. Imagine how quickly this goes away if a Medicare beneficiary has a stroke. Unlimited reimbursement can’t be a realistic thing, but minuscule caps on reimbursement demonstrates the continued poor value MedPAC places on physical therapy services.

The second recommendation is one of those curious things in healthcare. The recommendation concerns the multiple procedure payment reduction (MPPR) that went into effect in 2012. The MPPR basically says that if more than one unit of something is billed, the second unit will be billed at some percentage less. For 2013, MedPAC suggests that the MPPR be increased to 50%. Essentially, the first 15 minutes of therapeutic exercise is magically worth more than the second 15 minutes. Since the MPPR’s inception, a decline in payment for therapy services has resulted, further squeezing outpatient therapy services that already have a high administrative burden to treat Medicare beneficiaries. This further reduction will make this much worse.

In a letter from the American Physical Therapy Association (APTA) about the 2013 MedPAC recommendations, president Paul Rockar Jr, PT, DPT, MS, referred to the recommendations as “akin to doubling down on a bad policy.” I have to concur. It seems MedPAC has shifted too far on the mission of “save money” and isn’t considering the affect this has on patients with Medicare.

The APTA has an advocacy page, www.apta.org/Advocacy, where you can learn more about this, and members can take action and let their representatives in Congress know about the negative impact these recommendations have for their constituents with Medicare. The APTA remains in dialogue with policy makes and MedPAC, as well as continuing in advocacy efforts in Congress, but the collective public needs to raise a loud cry against these proposed changes.

Direct Access #SB924 & California #PhysicalTherapists

In the past, I have written about how the anti-POPTS (physician owned physical therapy services) movement in California  utilized technology and social media to educate the masses regarding referral for profit. Vist the Stop POPTS YouTube Channel  and stopPOPTS.org for more information.

Recently, a direct access to physical therapy services bill (Senate Bill-924) emerged in the California legislature. Great news!! Well, not so fast. Watch this short 16 second video in which the Assembly Appropriations Committee announces the amendments…

SB924 direct access to physical therapy services. Do pass as amended to require a diagnosis after initial 30 day period in order to continue to treatment. To amend consumer disclosure language and other technical amendments.

Read the entire text of SB-924: Physical therapists: direct access to services: professional corporations. For more legislative information you can visit Official California Legislative Information Webpage. The wording from the actual bill:

The bill would prohibit a physical therapist from treating a patient beyond 30 business days or 12 visits, whichever occurs first, unless the physical therapist receives a specified authorization from a person with a physician and surgeon’s certificate or from a person with a podiatric medicine certificate and acting within his or her scope of practice. The bill would require a physical therapist, prior to the initiation of treatment services, to provide a patient with a specified notice concerning the limitations on the direct treatment services.

Did I mention that this bill would also legalize physician owned physical therapy services?

This bill would add licensed physical therapists and licensed occupational therapists to the list of healing arts practitioners who may be shareholders, officers, directors, or professional employees of those corporations. The bill would also provide that specified healing arts licensees may be shareholders, officers, directors, or professional employees of a physical therapy corporation.

If you live in California, tell the following that back room deals are not OK. Utilize this letter template to write legislators and the governor. Patients deserve better. Seniors deserve better. Their consituents deserve better. California deseveres better. The national deserves better.

Minority Floor Leader Connie Conway @AssemblyConway Phone: (916) 319-2034 Fax: (916) 319-2134
Caucus Chair Jerry Hill P: (916) 319-2019 F: (916) 319-2119
Assistant Majority Whip Rober Hernandez @Roger_Hernandez P: (916) 319-2057 F: (916) 319-2157
Majority Whip Toni Atkins @toniatkins P: (916) 319-2076 F: (916) 319-2176
Asstistant Assembly Floor Leader Mike Allen P: (916) 319-2007 Fax: (916) 319-2107
Floor Leader Charles Calderon P: (916) 319-2058 F: (916) 319-2158
Speaker pro Tempore Fiona Ma @fionama P: (916) 319-2012 F: (916) 319-2112
President pro Tempore Darrell Steinberg P: (916) 651-4006 F: (916) 323-2263
Assemblyman Felipe Fuentes P: (916) 319-2039 F: (916) 319-2139
Assemblyman Mike Gatto @mikegatto P: (916) 319-2043 F: (916) 319-2143
And last, but certainly not least, Speaker of the California State Assembly John A Perez @SpeakerPerez P: (916) 319-2046 F: (916) 319-2146

Follow the #SB924 hastag as well as the following physical therapists on twitter: @ChrisReed1 @Jerry_DurhamPT and @RobertSnowDPT. California based physical therapy program University of the Pacific (moderated by Todd Davenport) @PacificDPTweet and @PittPT Pittsburg Physical Therapy student @MattDeBole. Tweet at @APTAadvocacy and The California Physical Therapy Association @CPTAtweets.

Who else may be interested?


Letter to CA Legislators Template (Google Document)
Pitt Physical Therapy Student Site: The Monday Memo

Senate Bill 924
SB-924: Physical therapists: direct access to services: professional corporations
Bill Text with Strike Through Amendments (PDF)

When a Bad Bill gets WORSE
Back Room Dealings by Mary Hayashi & John Perez

Senate Bill 924 Amended by Democrats, would legalize physician kick backs…


Term & Title Protection for the #PhysicalTherapist & #PhysicalTherapy

APTA Term Protection Ad

The American Physical Therapy Association recently constructed a Term and Title Resource Center regarding the use of the terms physical therapy and physiotherapy as well as the titles physical therapist, physiotherapist, PT, DPT, and MPT.

They have even constructed a 1 page advertisement, that I think is actually rather clever. The APTA announces

The full-page color advertisement will run in future editions of State Legislatures magazine, the monthly publication of the National Conference of State Legislatures which is provided to state legislators, legislative staff, and other state policy makers in all US jurisdictions.

I commend the APTA for their efforts and resources, which are no doubt, an important step. And, there have been some victories. Virginia successfully enacted term protection for physical therapy and title protection for physical therapists.

Unfortunately, physical therapists are currently losing this battle on both the legislative (lack of term protection laws), but just as importantly, the judicial level. In 2010, the Washington State Supreme Court issued an impactful ruling that dealt specifically with physician owned physical therapy services (POPTS). But, the ruling also has significant ramifications for the use of the term physical therapy.  Details about the ruling can be found in an APTA released statement. The Kentucky Supreme Court issued a similar opinion.

The Washington State Supreme Court Opinion states:

Physical therapy is one aspect of the practice of medicine. The practice of medicine is defined by RCW 18.71.011(1) as ‘[o]ffer[ing] or undertak[ing] to diagnose, cure, advise, or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality.’ This broad definition readily encompasses all the acts constituting the statutory definition of the practice of physical therapy.

Ouch. But, it gets worse. The Washington State Medical Association exclaimed “Big Win in Supreme Court!!!” following the ruling. They continue:

The decision represents a victory for physicians and medical practices, not only because it is now clear they can employ physical therapists, but because an adverse ruling could have outlawed their employment of other licensed health care professionals (such as nurses).

Double ouch. The ruling as well as the medical community’s reaction clearly illustrate that legislators, the judicial system, and physicians do not view physical therapy as a unique profession nor physical therapists as skilled, collaborative, unique members of the healthcare team. It appears physical therapy continues to be viewed as a prescribed or provided modality with physical therapists as mere technicians or employees under the physician umbrella.

We either need to more aggressive with our formal national, state, and local legislative lobbying and education (including legislators,  patients, colleagues, etc), or we we need to seek and secure allies within the medical and healthcare community, including but not limited to physicians. I vote for both.

What are you doing to #SolvePT? What should we do at the grassroots level?


Term and Title Resources via the American Physical Therapy Association
Term Protection Advertisement/Handout
Physician Owned Physical Therapy Services (POPTS) and Referral for Profit via AAOMPT Student Special Interest Group Blog
APTA Statement on WA Supreme Court Decision
WA Supreme Court Decision and Statement
Virginia Term Protection
Kentucky Court Ruling Information[/list]

Going social in the APTA House of Delegates: RC 23-12

Next week, the American Physical Therapy Association House of Delegates will convene for the 2012 session.  This year’s House will discuss and vote on a number of motions, but – as a self-proclaimed social media junkie – one motion in particular has caught my attention.  The motion, introduced by the Washington Chapter, is known as RC 23-12 and proposes to set standards of conduct for physical therapists, physical therapist assistants, and physical therapy students who use social media.  The exact language of the motion is as follows:


Whereas, Physical therapists (PT), physical therapist assistants (PTA) and physical therapy students (students) must be knowledgeable regarding the principles of patient/client privacy, confidentiality and identifiable patient/client information as it relates to social media;

Whereas, PTs, PTAs, and students should use privacy settings to safeguard personal information. PTs, PTAs and students should monitor their social media presence to make certain that the information on their own pages and content posted about them is in concert with the American Physical Therapy Association (APTA) Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant;

Whereas, PTs, PTAs, and students must be knowledgeable regarding employers’, educational institutions’, or clinical training sites’ published policies on personal social media sites;

Whereas, To uphold appropriate boundaries, PTs, PTAs, and students should consider having separate personal accounts;

Whereas, If a PT, PTA, or student sees content posted by a colleague that appears unprofessional, s/he has a responsibility to bring that content to the attention of the individual, so that the individual can remove or modify the content; and,

Whereas, PTs, PTAs and students can be held personally and legally responsible for their publicly made opinions and comments, even on personally maintained sites and pages;

Resolved, That physical therapists, physical therapist assistants, and physical therapy students should demonstrate appropriate conduct in social media activities.

SS: Physical therapists (PT), physical therapist assistants (PTA), and students are using social media for professional/work/educational purposes, as well as personal interactions. The overlap creates potential conflicts in patient/client management. PTs, PTAs and students must understand that their online actions and content may negatively impact their reputation among patients/clients and colleagues, impact their careers and undermine trust in the profession of physical therapy. Conduct is defined as a verb to behave or manage (oneself); or to direct in action or course; manage. The PT, PTA and student must use appropriate conduct in the use of social media as the professional team. Currently, there are no APTA guidelines available for social media. APTA members are required to maintain patient privacy by following APTA’s Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant, their respective state practice acts, and HIPAA rules at all time, including social media.

Whether you are an APTA member or not (you should be, join here), this motion could have significant implications for those of us who are already using social media, as well as those who may consider communicating using social media in the future.  What are your thoughts?  Is it time for the APTA to formally address professional use of social media?  Does this motion fairly and accurately describe social media and its uses?  If you do not support RC 23-12 as written, what are your suggestions to amend this motion?  What would you add?  What would you remove?

I urge you to share your thoughts on RC 23-12 in the comments below, join the #RC23 conversation on Twitter, and contact your state APTA delegate(s) to let them know how you feel about RC 23-12.  As a Delegate for the Kansas Chapter, I plan to be a vocal participant in this discussion, and I will share your thoughts at the House.  There will be no better way for me to illustrate the power of social media at the House of Delegates than by citing our very own social media discussions of RC 23-12.

Make your voice heard.  Together, we can shape the future of our profession – one status update, tweet, post, or comment at a time.

[icon style=”notice”]Update: A lively Google+ Hangout and Twitter conversation on the #RC23 hashtag has been taking place.[/icon]

RC23-12 Discussion on Google+

Summary of #RC23 discussion on Twitter via Storify.

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Kendra Gagnon is a new contributor to PT Think Tank. A pediatric specialist, she’s on faculty at the University of Kansas Medical Center and shares a common interest among PT Think Tank writers: she is a “self-proclaimed social media “junkie”, and uses technology and social media in the classroom to engage students and prepare them for using these technologies in the professional world.”

She blogs at Kendra Ped PT.

APTA Vision 2020: What’s your grade?

Alan Besselink, blogger and Austinite extraordinaire has written a thoughtful post entitled, “APTA’s Vision 2020: My 12 Year Report Card.” In the post, Alan breaks down the components of Vision 2020 and provides his summary of the progress toward each.

To review, here’s the Vision 2020 statement from the APTA:

“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.”

I’m sure certain parts of this resonate more with different folks. For Alan, the issue of Direct Access takes center stage. I agree with his critique of the APTA PR machine, which labels 40 something states as having some form of direct access to physical therapists…while in actuality, many of those states are not very gate-keeper free at all. Alan points out that the state we both practice in, Texas, is listed as a Direct Access state by APTA. I consider that false.

Here are Alan’s grades for each section:

  • Autonomous Practice: F
  • Direct Access: F
  • Doctor of Physical Therapy and Lifelong Education: F
  • Evidence-based Practice: F
  • Practitioner of Choice: F
  • Professionalism: A
  • Overall: F


Now, I’m not sure I agree with Alan on all of these grades (specifically the EBP and DPT grades), but he makes a good argument for each of his choices in his post. My question to you is, what do you think about the progress we’ve made on Vision 2020. As Alan points out, “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.” This may be a good opportunity to take stock and make some changes in strategy before we get too close to 2020 to change!

[icon style=”notice”]I’ll summarize the results of this poll in another post prior to the APTA Annual Conference.[/icon]

How do you Grade APTA Vision 2020 Progress

Physical therapist Blogger, Alan Besselink has already submitted his grade. What's yours?