Many comments and emails to me regarding the unintended consequences post. I blogged about this due to the fascinating admission by Pete Stark that the attempt to stop referral for profit thru legislation in fact contributed to its growth. I further compared the same phenomena when our profession sought for and ultimately obtained getting medicare numbers for POPTS clinics under the auspices that it can be tracked. In fact, this further fueled growth in POPTS by endorsing the whole notion of PTs working in physician clinics under other than “incident to” billing and more importantly did not result in being able to “track” rather we have more confusion in the data than clarity prior to going down this track.
My opinion is pretty straightforward, you can’t legislate behavior as people will find ways around it-much like the tax analogy that Mr. Stark used to describe the laws in his name’s failure. As was aptly pointed out to me that even my examples of pharmacy, Missouri, and S. Carolina have some exceptions (in the case of pharmacy, many docs have pre-packaged drugs available for purchase and in states that have essentially banned POPTS the “Foundation non-profit” model of PT exists in some physician practices.
However, we don’t have to look at broad legislation attempts and their unintended consequences-just look at CMS and their superimposed rules and their attempt to “slow down” growth in PT. The only published recent CMS data acknowledges doubling of rehab billing between 2000 and 2004 and as I point out in other blog posts, the premise of “growth is bad” is flawed in and of itself as growth in PT has the potential unintended consequences of lowering imaging, pharmacy, and surgical costs which has been documented. To decrease such growth we have superimposed rules like the 8 minute rule, technical auditing of signatures on plans of care, a whole new definition for “group therapy”, and a continued but inflation adjusted medicare cap (unless you work in a hospital) and now the craziest of them all-an exceptions process. Do we have any data that any of these have slowed growth? Absolutely not. Do we have any proof that this increases cost to providers and becomes a crazy inconvenience to patients? Absolutely-just look at the comments to CMS about them.
My least favorite topic-exceptions process is classic case of not totally realizing the unintended consequences of bad policy. It was primarily put in place to do 2 things-slow the growth of medicare in PT and to force documented medical necessity in the biggest sector of abuse-part B in skilled/long-term care facilities (LTC’s) and POPTS. The words “abuse” aren’t pejorative-rather CMS’ own description that they have documented 70–90% medical chart reviews in those setting don’t meet medicare standards for medical necessity or reasonableness of care. Instead of placing the exceptions process in those settings, they force it on all of us and now we go thru painstaking trouble to obtain an exception on 67 year old Mrs. Jones who just had open rotator cuff repair and who barely tolerates the pain of putting a hat on her head and will easily go over the medicare cap. As to LTC facilities? Just tack on a dementia diagnoses and you have essentially completed the exception process. It is much easier to get a doc or somebody at a nursing home to put dementia on a long list of diagnoses than it is to get thru the exception process on Mrs. Jones shoulder. I would bet that data will demonstrate significant growth in dementia diagnosis in long term care facilities for part B patients. I also realize that I am probably in the minority by not supporting continuation of this process but I firmly believe that the alternative (cap without exception) will give rise to more rumblings by patients who are grossly inconvenienced in the situations where they have to be transferred to a hospital who have high shortages of PT’s and provider complaints which will foster a quicker resolution to the “cap alternative” that has been promised for years. At least we know those consequences.
One last example of unintended consequences (for now!) is the inconsistent policy of CMS towards the treatment of PT students between Part A and outpatient Part B. In outpatient settings, the student PT (often a 3rd and on their last clinical) cannot treat a medicare patient without close and exclusive supervision by a PT. Different story altogether for Part A inpatient where they can. Although reasons for this discrepancy have never been to my knowledge articulated, it has resulted in some of our best clinical sites in the US not taking or limiting students because their medicare percentage is too high and they cannot afford the supervision requirement and loss of productivity! This lunacy flies in the face of the fact that more and more of our patients are going to be outpatient and medicare and fueling more damage to an already broken clinical education system for PT schools in the US (another topic for another time).
Thoughts?
