I've thought about this subject for several months - ever since March 2010 when MedPAC delivered its annual Report to the Congress: Medicare Payment Policy.
Now comes this recent article from The Annals of Internal Medicine, picked up on the Evidence in Motion blog, that verifies the implications of the MedPAC report and my suspicions.
The report was black and white evidence that our government is biased against small healthcare providers - where 70% of American healthcare takes place!
Medicare "guess-timates" on adjustments to the Physician Fee Schedule based on access to capital markets for selected healthcare sectors.
"Substantial increases in the number of providers may suggest that payments are more than adequate and could raise concerns about the value of the services being furnished...Guess what? Small clinics like mine and yours DON'T have access to the capital markets! These days we may not even have access to bank lines-of-credit anymore!
The volume of services can be an indirect indicator of beneficiary access to services...
Volume is also an indicator of payment adequacy; an increase in volume beyond that expected for the increase in the number of beneficiaries could suggest that Medicare’s payment rates are too high."
Providers’ access to capital
"Access to capital is necessary for providers to maintain and modernize their facilities and capabilities for patient care.
Widespread inability to access capital throughout a sector might in part reflect on the adequacy of Medicare payments (or, in some cases, even on the expectation of changes in the adequacy of Medicare payments).
However, access to capital may not be a useful indicator of the adequacy of Medicare payments when the sector has little need for large capital investments, when providers derive most of their payments from other payers or other lines of business, or when conditions in the credit markets are extreme."
The MedPAC report implies that only large firms with scale economies, access to capital markets and administrative staff that can maximize revenue and compliance will succeed in the future.
The Annals article, titled The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges was written by physicians with close ties to the present administration. Their opinion echoed the MedPAC report:
"The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.No rebuttal was printed by the Annals editors but many online readers voiced vigorous opposition to the politically positive tone of the Annals article.
The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience."
Physical Therapists and the Multiple Procedures Payment Reduction Policy (MPPR)
The recent, proposed Multiple Procedure Payment Reduction (MPPR), is just the end result of policy discussions at high levels that those of us in private practice can only react to - we usually don't get a voice in these decisions.
Hopefully, many of us wrote letters to the head of the Centers for Medicare Services, Dr. Donald Berwick, pointing out that the projected 13% revenue "savings" will be disasterous for private practice physical therapists and their patients.
Here is a copy of the letter I sent. The comment period closed August 24th and we'll learn the final adjudication November 1, 2010.
Take Home Message
I don't think the future of physical therapy belongs just to large firms - private practice physical therapists can still effectively compete.
The Annals authors, however, do not believe managing future change is possible in small practices:
"Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."They appear to have reached the conclusion already that small businesses in medicine and physical therapy will go the way of the dinosaur.
In order to prevent our own extinction we will need to gain control of the one thing that we have that the government wants - our patient data. We need to control not just outcomes data but also baseline data on patient characteristics that affect outcome. Also, we need to show that our decisions on patient care are BETTER than physicians decisions.
Why are physicians referring patients to us? We should be referring patients to them! We should be the point of entry!
But, to gain control of our data we will need better systems for managing data. Not just Electronic Medical Records (EMR). And not just Clinical Decision Support (CDS) systems, either.
We'll need a marriage of EMR and CDS that will improvement the process of care - as delivered by physical therapists. We'll need to show that ONE care process in particular: care delivered hands-on by physical therapists DOES lead to better outcomes.
While outcomes are difficult to measure, process measures are much easier. I have not been especially happy with many burdensome process measures in physical therapy but hands-on care is a "no-brainer".
This new study in the August 2010 Physical Therapy Journal is just the second published article showing that PT process measures improve patient outcomes.
What to Do?
Ask your EMR vendor about integrated decision support - what are you doing with your data? If you don't have an EMR you can still use pen-and-paper decision support tools - usually paper templates - that can be stored in the patients' chart.
These templates can be set up to predict the duration, frequency, total cost and expected outcome. Baseline co-factors can alert us ahead of time to those patients at risk for "failing" in physical therapy - these are the "outliers" that Medicare so desperately wants to identify.
Some "outliers" will need more therapy, some will need referral to psychological screening and some will need surgery.
I hope we can convince the Congress soon that the most efficient setting for physical therapists to serve Americans in this way is often the small, outpatient physical therapy office.