Every year, a good sized group of physical therapists gather to discuss, debate, and present issues that impact private practice physical therapists.  The “Graham Sessions” has become a great venue for many things-including a great spot to grouse about all the threats impacting the profession as well as the presentation of new and different ideas.  The Private Practice Section (PPS) originated the concept with support from APTA .  Last fall, a special regional Graham Session included sponsorship by the newly formed Physical Therapy Business Alliance. The concept for EIM’s Executive Management Program in Private Practice in part originated out of these sessions and continues to enjoy a great strategic relationship with PPS.  This year there is an added dimension with short TED like talks.  I was asked to do one and originally consented until I found out that it was next to a weekend of the RC-3 Task Force (it has another name which is quite long and impossible to remember) and just weeks before CSM and Foundation for Physical Therapy meetings where I am privileged to be a Trustee.  In other words, I just can’t justify more time on the road for volunteer work!  However, I do want to present my idea which I am calling the “PT Fix”.

For the last 15 years, the formula used to determine how much doctors  (and us PT’s) get paid has not kept up with the growth in health-care costs.  Very predictably over the years (sometimes even 30 days or most recent 2 months), Congress has reliably passed a “doc fix” and additional funds are found to cover the shortfall, in some cases actually providing a slight raise.  The root of the problem is in the formula called Sustainable Growth Rate (SGR).  Medicare in their own stupidity used their 1990’s spending as a baseline that when combined with their prediction in overall economic growth would serve as the future medicare budgets.  While reminiscent of the former commissioner of the U.S. patent office, Charles Duel’s quote in 1899 that “everything that can be invented has been invented”, the formula never factored innovation in healthcare or an aging population that not surprisingly causes health costs to outpace the general economy.  The impact is devastating economically leaving the entitlement of medicare with multi-billion dollar shortfalls.  Rather then get to the root of the problem (a recurring government theme) the options when medicare money runs out include cutting doctor’s pay or provide additional funds.  At least twice in the past three years, their has even been a creative in between solution felt by those in private practice during the August months when they delay payment so that it can carry into a new fiscal year.  The most fruitful year of the “doc fixes” was 2010 when there were five separate fixes, none longer than six months.  In 2011, the “doc fix” cost $19 billion.

The Obama administratively has endorsed repeal of the SGR formula as well as essentially every professional medical society.  This is obviously more easily stated than done when you factor in that CBO estimates that it would take an additional allocation of $300 billion which is harder to find than snow in Colorado this year.  My opinion is that this theatre of the absurdity will continue for awhile, not exactly a Nostradamus prediction.  Of course, PT’s who are incredible at grass roots efforts will get numerous emails encouraging them with form letters and scripts to write their legislators and extend the “doc fix” when it sets to expire in under two months.  Along side of this effort, will be instructions on extending the exception’s process-something that I started writing about its craziness in Nov of 2007 which you can view here and here.  While it’s analogy to the “doc fix” is uncanny, it doesn’t have anywhere near the economic implications.

My idea is the “PT Fix”.  Under the premise that don’t complain about a problem unless you have a solution, I would propose that we have CMS eliminate the group therapy code-97150. According to CMS’ 2010 data, this code was allowed 674,473 times and CMS paid out over 10 million dollars.  The problems with the group therapy code are the fear of using it, its counterintuitive definition, cost of compliance and monitoring, and the high variability of its use or lack of appropriate use.  My personal experience and review show that it is likely used too little with this CMS “billing scenario” document adding to the confusion and fear. Along with eliminating the code, CMS would also amend their explicit provider rules and allow PT’s to act within the scope and their authority.  Part 2 of the “PT Fix” is amending the inconsistent CMS document: Skilled therapy: Benefits Policy Manual, 100-02, Chapter 15, Sections 220 and 230.  This is the document that defines everything from PT to Non-physician practitioners (NPP) and everything in between and introduces my number one pet peeve in the world, the term  “skilled” physical therapy. While you would need the largest super bubble bub’s daddy gum, to stay awake while reading this document, you can’t help notice a recurring theme of referring to “licensed or otherwise regulated in the state in which practicing” regarding a practitioner’s scope and authority.  Simply removing the document’s explicit provider list of “skilled” physical therapy would allow PT’s to practice within their licensed craft.  There is plenty of precedence for this-namely physicians who would never allow the creation of such superimposed lists. By the way, here is the Policy Manual’s definition of Qualified Professional of physical therapy and many will find the list of available providers surprising:

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.  Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.  Assistants are limited in the services they may provide (see section 230.1 and 230.2) and may not supervise others.

Part 3 of the “PT fix” is the easiest. The therapy cap and exceptions process should be eliminated.  CMS’ own data show that despite a competitive advantage that hospital’s have had by not having a therapy cap, there continues to be less patients accessing hospital based departments.  In 2010, independent PT’s had about $1.7 Billion of the approximate $4.5 of the outpatient therapy pie and it is unknown which part of “independent” is really self referral as this blog has discussed.  What we do know is that physical therapy overall is a very small part of the CMS outpatient expenditures with only 5 codes even showing up in the top 200 CPT codes that CMS paid (no breakdown of those 5 codes to determine if licensed PT was the provider).  While I believe a part 4 of the “PT fix” should be direct access, it has already been proposed and its only successful sniff has been a proposed demonstration project in a supposed CMS innovation center.  Therefore, I won’t spoil “PT Fix” with an initiative that has been attempted.  We want this to be fresh.

To summarize, the “PT fix” consists of savings in the form of elimination of the group therapy code with amending the language of qualified professionals in the CMS benefits manual and elimination of the therapy caps and the current exceptions process.  In the lingo of TED, which has inspired these type talks at the Graham Sessions, I believe this is “an idea worth spreading”.

@physicaltherapy