Selasa, 29 September 2009

Physical Therapy, Silver Coins and Green Eyeshades


We need a common coin of the realm.

After Napoleon's final defeat at the Battle of Waterloo on June 18, 1815 the British bond market rallied as investors predicted lower government borrowing for future wars. Nathan Rothschild arrived in London just hours ahead of the news of the battle's outcome and began buying up British war bonds at bargain basement prices.

Bond prices rose as yields fell and Rothschild sold at a huge profit. Rothschild's future was made in those months following Waterloo. Many sources credit Rothschild as the pre-eminent banker, speculator and, some say, the most powerful financier of the nineteenth century.

Nathan RothschildAfter securing his fortune Nathan Rothschild went on to become famous and also managed to create a standard that still affects our lives today. He demanded, and got, due to his money and influence, a uniform system for paying bond holders in sterling silver - no matter which country they were from. Investors no longer had to go to London to receive their bond coupon payments and sterling silver became the coin of the European investing realm.

Improvements in payments made bonds more attractive to investors and, ultimately, easier for Rothschild to sell. Bond holders were better off, governments gained access to new funding and Rothschild got richer.

I see a parallel here.

Couldn't physical therapists demand a uniform measurement system for rehabilitation outcomes? If all rehabilitation professionals had a common measurement system (eg: standardized performance, self-report, impairment or classification measures) then physical therapist outcomes could be compared with other rehab professionals. Right now, the only available comparisons are based on setting (eg: POPTS, PTPP, hospitals, etc.) and the only available measure is cost.

What if physical therapists could compete with physicians on outcomes?

Physician owned physical therapy clinics (POPTs) are slightly lower in annual Medicare, per beneficiary costs ($522) than their Physical Therapist in Private Practice (PTPP) peers ($871) but that may be due to the 'Flying Below the Radar' effect.

Unfortunately, cost is not the best measure of competitiveness. Not if you believe that quality service is a better measure. WalMart competes on cost - would you buy healthcare from WalMart?

Physical Therapists under Automated Review

Right now, in America, powerful computer algorithms are sifting your claims data and looking for patterns outside the 'bell curve' - do you do a lot of manual therapy?

Four manual therapy units (1 hour) per visit? You are outside the curve.

Automated reviews, conducted by Recovery Audit Contractors (men in green eyeshades), are looking for duplicate payments like two spinal tractions in one day. Spinal traction is a 'supervised modality' - you set it and go treat another patient. Totally legal - however you can't charge more than one per day per patient.

Recovery Audit Contractors (RACs) made some good money in Florida, California and New York from 2005 to 2008 during the RAC Demonstration Audit with automated reviews.

RECOVERED AMOUNTNUMBER OF PROVIDERSTOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008~$80/year7
Average Florida Provider: 2006$13521,927
Average California Provider: 2006$21650,054

I posted this chart originally on June 8, 2009 from my own clinic data as well as US government published data from the RAC Demonstration Audit Report (June 2008)

I define 'good money' as the piddling amount RACs 'recovered' from me because cost/investment = $0 and return = $80. To the men in green eyeshades the calculated ROI is infinite.

RAC accountants in green eyeshadesMichael Apolski's Medicare Update blog is quoted in the September 2009 issue of Orthopaedic Practice Management - he discusses automated reviews on page 99.
"RACs can analyze claims using two methods. During “automated” review, they attempt to find “the low-hanging fruit” by making a claim determination at the system level without even reviewing the medical record, Apolskis says."
Alternative Physical Therapy Payments

The current lead contender for a 'common coin of the realm' is a tool being developed by a private-public partnership, Research Triangle Institute (RTI).

I have a couple of concerns with RTI's Developing Outpatient Therapy Payment Alternatives (DOTPA) project:
  1. Despite their attempts at outreach they still have a government mandate - they can ram it down our throats, if they want to.

  2. Their assessment tool is expected to take 15-30 minutes per patient! No time left for patient-therapist collaboration or establishing rapport.

  3. Is RTI re-inventing the wheel? Physical therapists already know how to assess our patients - do we need a new setting-specific tool? Couldn't we do better with a set of condition-specific measures for common, high-volume conditions like the Oswesty for lower back pain or the SPADI for shoulder pain? Let the clinician choose.

  4. How many physicians could manage the transition from profit-driven POPTs to outcomes-driven care? Would running a PT clinic under those circumstances (ie: when you're not a PT) be worth the 'hassle"?
Nathan Rothschild seized a singular moment in world history and used it to shape the future of finance - could physical therapists seize healthcare reform as a springboard to position evidence based physical therapy as the universal standard by which all rehabilitation professionals are judged?

Could we 'sell' physical therapy to a skeptical public of payers and government policymakers when we are all better off with outcomes?

Physical Therapy, Silver Coins and Green Eyeshades Rating: 4.5 Diposkan Oleh: Elvina dara

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