Faculty Spotlight: Dr. Ira Gorman discusses healthcare policy and PT advocacy

Like most physical therapists, my passion for PT arose from the desire to empower people to achieve their greatest state of well-being and functional independence. However, as I progress in my education, I am learning that the simple goal of helping people can be far more complex in our convoluted healthcare system. Furthermore, if I want to truly serve society, I cannot simply treat individual patients. I must advocate for larger changes through public health.

To elucidate some of the confusion around healthcare,  Dr. Ira Gorman speaks today about the current healthcare system, the need for awareness and advocacy to advance public health policies, and recent changes in the practice of PT.

-Priya Subramanian, SPT- Regis University

The Physical Therapy Outcomes Registry

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Blogger: Katie Baratta

My name is Katie Baratta and I just graduated from the Regis University School of Physical Therapy. I had the opportunity to spend two weeks at the APTA doing a student internship. I was able to talk to many different members of the APTA, attend the Federal Advocacy Forum, and learn more about what the APTA has been doing to move our profession forward. I’ve written a series of essays about my experiences here at the Association.

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Data… I love it! As a former engineer who analyzed a lot of data in my pre-PT life, I find it fascinating to see how lots of tiny bits of information, combined together, can provide us with a more comprehensive picture.

The PT Outcomes Registry is one of APTA’s current projects to create a centralized database for outcome data. The idea is to track a set of prioritized outcome measures (currently there are nine outcomes, but this may expand) across the country. Clinicians perform the outcome assessment with the patient at the initial evaluation and again at discharge to measure the patient’s progress and then input the information into the computerized system. The PT Outcomes Registry then compiles the data from all practitioners so that practitioners can see how they measure against a benchmark of other providers.

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Timeline

The program is still in its pilot phase with 216 enrolled users (currently all practicing PTs, no PTAs) at 25 organizations. The most recent development is to include residents and fellows to compare their outcomes both during their residency/fellowship and again afterward to see how their outcomes change with time and experience. Later this year, APTA will collect feedback via user survey of pilot users regarding usability, pros/cons, glitches, and so forth. The team at APTA will then incorporate this feedback into the PT Outcomes Registry system.

The Registry will officially launch at the beginning of 2017, at which time any clinical site will be able to join. Clinicians will pay to enroll in the program, which will give them access to the aggregated data to see how their practice stacks up against national benchmarks. The service will not be limited to APTA members. Karen Chesbrough, the outcomes registry director, states that by the end of 2017 the APTA would love to have 1000 users, with the long-term goal of involving as many clinicians/sites as possible to get as accurate a picture of current practice as possible.

Which types of data are included?

The current outcomes include global measures, such as AM-PAC™ (Activity Measure for Post-Acute Care™), PROMIS (Patient Reported Outcomes Measurement Information System), and OPTIMAL (Outpatient Physical Therapy Improvement in Movement Assessment Log). There are also regional/body-specific outcome measures such as NDI and Oswestry. Other data includes clinician profiles, patient demographics, and pain ratings; practitioners have the ability to enter data at treatment visits along with at initial evaluations, reassessment, and discharge. The types of outcomes included are vetted through an independent group of clinicians and academics (including one Canadian!) called the Scientific Advisory Panel.

The Scientific Advisory Panel is working in conjunction with the SIGs (Special Interest Groups) to develop prioritized objective data that the clinician would also collect as part of the PT Outcomes Registry based on the patient’s diagnosis. These modules may be specific to cervical pain or to infant torticollis, for example, and would include relevant ROM or other objective data.

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How does PT Outcomes Registry collect the data?

During the pilot program, enrollees are entering the data manually. Enrolled clinicians—or their clinic’s administrative support personnel—will log in to the system and select different tabs and boxes to enter the data, much like they do for electronic documentation of patient records.

However, manual data collection is time-consuming, so the current push within the project’s development is to build software “bridges” with all of the various EMR (electronic medical records) systems. These bridges would allow a computer program to connect the PT Outcomes Registry with each EMR system to pull the relevant pieces of data into the database. Each type of information (eg KOOS at initial eval, patient age, etc) will have an associated tag in the registry database, and each EMR will tag the same variable in their database so that the computer program will be able to match the data from the patient records to the PT Outcomes Registry. One EMR has already signed on to the project, and APTA is working to get more to participate. This will streamline the process significantly and will likely increase participation as less time and energy will be required for individual clinicians to enter the data by hand.

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What does this mean for clinicians?

Being a part of the PT Outcomes Registry would allow clinicians to see how their practice stacks up against others throughout the country. If a particular clinic performed very favorably within the Registry, it would be able to advertise this fact to patients and to different entities that may want to contract with the clinic. Participation in the PT Outcomes Registry would also enable a clinic to pinpoint how to improve poor performance in a particular area that they may not have previously recognized without the aggregate data.

The PT Outcomes Registry will provide objective information to support the assertion that PT restores function. We can then use this information to demonstrate our value to different organizations, whether that is with a hospital, an insurance organization, or to the general public.

The outcomes registry director also sees this information as eventually being linked to reimbursement. Linking outcomes to reimbursement would continue the trend to move away from fee-for-service and toward a value-based payment structure. A value-based payment structure rewards effective clinical practice, rather than performing treatment units with the highest reimbursement rates. This would be a win-win for evidence-based practitioners, as well as for their patients.

Eventually, with enough data, there is potential for the information to be used for research as well; the Outcomes Registry represents the exciting future of our profession!

PT Outcomes Registry Site | More info from the APTA

 

Physical Therapy Classification and Payment System: a Discussion with Lindsay Still

 

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Blogger: Katie Baratta

My name is Katie Baratta and I just graduated from the Regis University School of Physical Therapy. I had the opportunity to spend two weeks at the APTA doing a student internship. I was able to talk to many different members of the APTA, attend the Federal Advocacy Forum, and learn more about what the APTA has been doing to move our profession forward. I’ve written a series of essays about my experiences here at the Association.

Interview with Lindsay Still, Senior Payment Specialist

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I talked with Lindsay Still, a Senior Payment Specialist, and she explained the current state of the PTCPS.  Read a summary of our interview below!

Overview

The Physical Therapy Classification and Payment System (PTCPS) is an ongoing initiative that was developed as an alternative to the current, fee-for-service codes—ones that easily fail to capture the true value of what PTs do—and instead particularly account for the complexity and skill of clinical expertise required for patients with more involved presentations. It also incorporates the use of standardized outcome measures. PTCPS would include a single CPT (Current Procedural Technology) code for the entire treatment session versus the assortment of 15-minute unit codes that we’re used to today.

The system has gone through multiple iterations in the past several years, and was developed by the APTA in collaboration with a specialty work group within the AMA (American Medical Association) involving members from the professional organizations of OTs, massage therapists, athletic trainers, speech-language pathologists, chiropractors, psychologists, optometrists, podiatrists, physiatrists, neurologists, orthopedic surgeons, osteopathic physicians, and representatives of CMS (Centers for Medicare & Medicaid Services).

Structure of the new coding system

Under the new system, there would be three new evaluation codes that puts a patient into an initial category of lower, moderate, or higher complexity. Certain documentation criteria (e.g. under patient history, presentation, or plan of care) would determine which of the three eval codes you would select. For example, the number of comorbidities for a given patient would play a role in the eval code selection. There would also be a single code for any re-eval visit.

As currently structured, the proposed PTCPS would also incorporate five treatment codes, based on the overall complexity of the patient’s presentation and treatments. These codes, much like our current CPT code for evals (97001 Physical Therapy Evaluation), would not have a set time frame or number of units associated with it. However, treatment billed under the lowest complexity code would likely be much shorter than a treatment session under the highest complexity code, and the reimbursements would reflect this fact.

Implementation

In 2014, pilot testing of the new system was performed with PTs using the new system to code/bill for hypothetical patients, as well as using the new system to code the treatments of actual patients previously coded with the existing system. This testing occurred in various care settings. Overall, the clinicians were very consistent in their ability to categorize patients with the new initial eval codes. However, for the intervention codes, the pilot clinicians were only able to consistently categorize those patients with the least complex and most complex presentations. There was significant disagreement between PTs in regards to cases that fell within the different “moderate” treatment categories.

The definitions and valuation of the proposed eval codes were reviewed and approved by the RUC (Relative Value Scale Update Committee) and will now require CMS approval. Lindsay is hopeful that CMS will accept the new eval codes, as they will be budget-neutral. In August of 2016, CMS will release the 2017 Medicare Physician Fee Schedule Final Rule; this should include the new PT evaluation and reevaluation codes. The new codes will go live on January 1, 2017. PTs will have three brand-new CPT codes to replace the current 97001 Physical Therapy Evaluation. The APTA will provide training and support to clinicians during the time leading up to the release of the new eval codes.

Impediments to the impending treatment code change

The new treatment codes will require further review and refinement, given their inconsistency of use during the pilot testing. This will likely be an interactive process, and not without controversy from the perspective of payers (insurance companies). In the meantime, the RUC has requested a “backup plan” to address ten CPT codes commonly used by PTs which have been identified as “potentially misvalued codes,” most of which PTs probably use frequently:

  • 97032 attended electrical stimulation
  • 97035 ultrasound
  • 97110 therapeutic exercise
  • 97112 neuromuscular reeducation
  • 97113 aquatic therapy with therapeutic exercise
  • 97116 gait training
  • 97140 manual therapy
  • 97530 therapeutic activities
  • 97535 self care home management training
  • G0283 unattended electrical stimulation (non-wound)

These codes are flagged  because they represent a high reimbursement rate and have not been assessed since 1994.

As a result, the APTA is currently redirecting efforts to provide replacements to those 10 codes rather than waiting for the codes to be reevaluated for us. The new treatment codes the APTA envisions to replace them with would be procedure-based: you would still bill in 15-minute increments. However, they would be streamlined; there would be fewer codes, and the codes would reflect the types of treatment PTs currently perform in practice (as opposed to focusing on what treatments PTs may have historically performed).

Future of the proposed treatment codes

The more general patient- and value-based treatment codes initially envisioned by the APTA are still in the works, but Lindsay foresees a longer process before fruition: it will require all parties to agree on a coding system that accurately and cost-effectively describes the type of treatments that PTs perform for patients. This includes the third-party payers who generally prefer the current setup of treatment codes based on billable units. The current coding system is easy to monitor for abuse or overuse of treatments.

I asked Lindsay if she saw outcome measures as one way of giving insurance companies some power to track the value of treatments under the proposed system. While they wouldn’t be able to screen specific procedures in the same way that they are able to under the current system, they would be able to, for example, monitor whether the progress of a “low complexity” patient was lagging behind what would be expected given that patient’s presentation.

She agreed that this could work in theory, but felt that we still have a long way to go in terms of standardization of outcome data across the spectrum of patient presentation. This is one of the reasons the PT Outcomes Registry will be so important! These two issues truly are intertwined in the future of value-based billing for PT services.

For more information, visit: http://www.apta.org/PTCPS and check out the Timeline for payment reform.

From Practicing Clinician to APTA Employee: an Interview with Anne Reicherter

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Blogger: Katie Baratta

My name is Katie Baratta and I just graduated from the Regis University School of Physical Therapy. I had the opportunity to spend two weeks at the APTA doing a student internship. I was able to talk to many different members of the APTA, attend the Federal Advocacy Forum, and learn more about what the APTA has been doing to move our profession forward. I’ve written a series of essays about my experiences here at the Association.

Interview with Anne Reicherter PT, DPT, PhD, OCS, CHES

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What do you do at the APTA?

Anne was hired by the APTA last spring (2015) and works as a Senior Practice Specialist. In this position, she oversees the PTnow website, which provides practicing therapists with tools for evidence-based practice and includes access to current research and other clinical resources. A good portion of her workweek is dedicated to improving the services offered by PTnow* and working to facilitate access and utilization by APTA members.

Practice Specialists at the APTA are all licensed PTs and also work as consultants on whichever issues are current hot topics regarding our scope of practice. For example, dry needling is currently being discussed and spinal manipulation has been a historically important issue.  As one of the few PTs on staff at the APTA, Anne and her colleagues in the Practice Department review products created by the APTA marketing team or other departments prior to publication to ensure that they are accurate from a clinical and research perspective. She says she will sometimes look at a photo and say that “a PT wouldn’t perform that intervention,” or  that they “wouldn’t stand that far from the patient.” Another current project of Anne’s is a collaboration with APTA researchers on an article for the Journal of Health Policy and Administration about obesity. One of her other areas of focus is the importance of work-life balance within the profession.

How did you come to work at the APTA?

Anne graduated with a BS in Physical Therapy at University of Pittsburgh and then worked in a mixed inpatient and outpatient setting at a hospital. She describes that this was fairly common at the time, and that–with few exceptions–PTs were given a lot of autonomy from their referring providers, and that there was not yet a fee-for-service model at the HMO for which she worked. After ten years in that setting, she wanted to progress her career and knowledge, so she attended night school to obtain her Masters of Health Education. In subsequent years she held a variety of jobs in the educational setting (working for Howard University in DC and the University of Maryland, Baltimore) as well as in other clinical settings, including orthopedics and home health. During this time, she obtained her PhD in Educational Psychology, as well as her transitional DPT. She has also performed some educational consulting for various DPT programs.

The position at the APTA for a PT Practice Specialist opened up at the same time that Anne was searching for something more. She wanted a job that fit with her interests and values: the ability to participate in  writing and publishing, advancing the profession through APTA initiatives, and expanding her own knowledge made the job an excellent fit. She says that these meaningful components–including continuing education–were built into her practice as a new clinician (for example, if there was a “lunch and learn” on a given day, the clinicians would leave a bit early that day), as well as into her work as faculty. Today, however, there is an increased emphasis on productivity and fee-for-service; thus, there is limited time and resources allocated to the pursuit of continuing education that distinguish us as professionals. Anne described the difference between professionals and technicians: professionals design a plan of care and add value to the system with professional discernment, and technicians simply deliver a procedure. To maintain the high expectations set of PTs as professionals, most PTs today must spend time beyond their paid workweek to pursue continuing education, APTA involvement, and evidence-based practice.

Where do we plan to see change in the typical PT’s work-life balance?

Anne replied that one of the biggest initiatives currently is the push to change from a billing system with a procedural focus (for example, billing for “therapeutic exercises” x15 min or “therapeutic ultrasound” x15 min) to one based on value. Current reimbursement accounts merely for the delivery of a procedure or modality for a set unit of time, but it does not account for our clinical judgement as professionals. I’ll go more into this initiative in next week’s blog post.

Any advice for new clinicians starting out in their career?

Anne’s advice to new graduates is to consider whether a job or position allows for and encourages professional development: do they fund continuing education? Do they have on-site mentoring programs you can participate in? She also advises new graduates to not allow mentoring to be limited to colleagues within your particular clinical setting but to continue to seek out a supportive network of clinicians for support as you begin to navigate your professional career.

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*PTnow is a valuable resource for us, as new clinicians, to perform literature searches after graduation (as we’ll no longer have access to the school’s library search function) as well as to access clinical reviews, clinical practice guidelines, and clinical summaries prepared by respected experts within the field of physical therapy.

If you haven’t visited the website, you should definitely check it out: ptnow.org

 

Direct Access: Insight into Some of the Barriers and Current Initiatives

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Blogger: Katie Baratta

My name is Katie Baratta and I just graduated from the Regis University School of Physical Therapy. I had the opportunity to spend two weeks at the APTA doing a student internship. I was able to talk to many different members of the APTA, attend the Federal Advocacy Forum, and learn more about what the APTA has been doing to move our profession forward. I’ve written a series of essays about my experiences here at the Association.

I met with Wanda Evans PT, MHS, CKTP (Senior Payment Specialist) and Elise Latawiec MPH, PT (Senior Specialist, Practice Management) who provided me with their insider understanding on this topic as well as directed me toward further resources.

Direct access physical therapy care means that a patient does not require a referral from a physician or other provider prior to a PT evaluation and/or treatment. All graduating Physical Therapists are required to have a DPT–a clinical doctorate–and, thus, they receive extensive training in the ability to recognize “red flags” and refer patients to the appropriate provider when it becomes apparent that the patient may be at risk for something more severe than musculoskeletal involvement.  Studies demonstrate that direct access decreases the time following an injury to the start of the patient’s PT care, reduces the number of visits of therapy needed and results in lower overall costs. Thus, PTs are not only appropriate for this role, but they can end up saving time, money, and patient suffering (as well as costs for the healthcare system overall).

Legislation

There are currently various types of direct access in all 50 states. Each state has jurisdiction over its own Practice Act, which is why there is some discrepancy from one state to another (state-by-state comparison). There are 18 states with unrestricted direct access—this includes Colorado! Some states require specific certification for a PT to provide direct access care, and others allow only an initial evaluation plus a set number of follow-up visits before the PT must contact the patient’s primary care provider. States with limitations in their practice act for direct access are fighting every day for legislative changes to eliminate these barriers; the APTA is aware of this and is actively assisting in these state-level legislative efforts.

However, the legal foundation is only the first step to getting patients the direct access care that we know would be beneficial. Common barriers to direct access that PTs reported in an APTA survey last year include reimbursement concerns, limitations in marketing, fear of alienating referral sources, restrictions by the PT’s employer, and lack of knowledge of state direct access laws.

Reimbursement                                      

Historically, third-party payers (ie insurance companies) have required a referral from a physician or other designated professional. Aside from Medicare/Medicaid and other federal programs like the VA or Armed Services (which have their own regulations on Direct Access), insurance policies vary by carrier and on a state-to-state basis. As the state legislation changes, the payers have been slowly adapting, with some payers more progressive than others in regards to reimbursement for direct access services. The APTA has been engaging with payers directly to eliminate the referral requirement at events such as the Insurance Forum, in comment letters, during in-person meetings, and in their day-to-day contacts. The APTA communicates this message to large employers who create their own insurance policies for their employees, as well, and are thus able to help employers set the terms of the insurance contract for their employees independently.

How can individual APTA members get involved on the reimbursement front? Each state chapter has a Reimbursement Chair.  The Chair’s responsibilities include learning as much as possible about trends with different payers in that state (and taking note if a lot of PTs have been reaching out with similar issues or complaints regarding the same payer) and assisting those therapists within their own state. The APTA nationally works in conjunction with the state chapters on payment/insurance issues and helps to connect states together when confronted with similar challenges. Patients and their advocates can also petition their Insurance Commissioner if they are inappropriately denied care or access to medically necessary services. The Insurance Commissioner advocates for consumers; s/he does not represent the insurance carrier.

Fear of alienating referral sources

Wanda and Elise described several studies in which direct access evidenced no negative impact on the physician-patient relationship. In fact, a key component of direct access is the necessity of PTs to refer patients to the appropriate provider when a patient’s symptoms and underlying pathologies are outside of our scope of practice. Given that PTs must make referrals back to other providers, it becomes a mutually beneficial relationship amongst different healthcare practitioners.

Education

A lot of concern stems from a a lack of education on the part of employers, insurers and potential patients. PTs need to demonstrate their clinical excellence to, essentially, prove that we are worthy of this responsibility, as well as to continue to educate all stakeholders on the importance and benefit of getting PT before medication/surgery. The first step for every PT is to become educated on what your state’s practice act specifically says about direct access and understand any limitations that may be in effect.  Educating patients, employers, and other healthcare practitioners is the next step. The APTA has developed many resources detailing the benefits and safety of direct access available online (more info).

Resistance to Change or Pushing for Progress?

There are some PTs who are more comfortable in the traditional referral arrangement than with unrestricted direct access. They may not want the additional responsibility, or they may simply prefer to do what they have always done.  That is okay!  Nobody is looking to force them to become direct access providers.

However, if you are one of the PTs who cares about the transition toward direct access and autonomy as a practitioner, make sure you’re an active member of the APTA! This is essential to better educate yourself, your patients, and other healthcare providers and to develop a strong voice with your state chapter and insurance agencies.

For more information on the current APTA involvement, as well as additional resources, check out its Direct Access page.