Therapy Services in Danger

[BlueBlue8]

Found this letter:

"On June 25, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that updates 2011 payment rates for physician services, outpatient physical therapy services, and other services. In the rule, CMS proposes to implement a multiple procedure payment reduction (MPPR) policy that would result in significant reductions in payment for outpatient therapy services, regardless of the setting in which the services are delivered. It will apply to physician offices, outpatient private practice settings and outpatient services in hospitals, as well as some home health and skilled nursing services (Part B)."

And the really interesting part:
"Additionally, individuals considering a career in physical therapy may reconsider their choice. The inability to serve the rehabilitation needs of seniors and individuals with disabilities due to unsustainable payment cuts would limit access today and has the potential to worsen health care work force issues in the future."

Source: http://trib.com/news/opinion/mailbag/article_416786ae-8c1f-5f9f-baaa-35cc8dd8d928.html

Yikes

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[MotionDoc]

Found this letter:

"On June 25, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that updates 2011 payment rates for physician services, outpatient physical therapy services, and other services. In the rule, CMS proposes to implement a multiple procedure payment reduction (MPPR) policy that would result in significant reductions in payment for outpatient therapy services, regardless of the setting in which the services are delivered. It will apply to physician offices, outpatient private practice settings and outpatient services in hospitals, as well as some home health and skilled nursing services (Part B)."

And the really interesting part:
"Additionally, individuals considering a career in physical therapy may reconsider their choice. The inability to serve the rehabilitation needs of seniors and individuals with disabilities due to unsustainable payment cuts would limit access today and has the potential to worsen health care work force issues in the future."

Source: http://trib.com/news/opinion/mailbag/article_416786ae-8c1f-5f9f-baaa-35cc8dd8d928.html

Yikes

This is just me thinking out loud:

Assuming the worst case scenario of complete denial of reimbursement for physical therapy services, I believe the profession can still flourish (potentially to a greater degree than it currently is). This scenario would usher in a fee for service model of physical therapy practice (the only way to sustain a PT business in this "frowned upon" future). Considering my belief, and that of many others, that physical therapy is an essential service for many, just like in the recreation and athletic arenas where millions (if not billions) of dollars flood the personal training and sports coaching market, in the MSK healthcare arena, the same will happen for
everyone from your LBP to your post-neuro patient populations.

IF physical therapy is not a valued and necessary service, then it deserves to fail and fade away into the history books. IF, on the other hand, physical therapy is essential to the lives of various patient populations, then it may in fact thrive in this "worst-case scenario". I have always held the belief that the current system actually stifles PT growth secondary to fostering decreased quality of care in clinics that must increase hourly quotas to keep up with decreasing reimbursement.

 

[jess818]

Yikes is right! Interested to hear what others think...

 

[jbizzle]

Isn't this on the OPINION column???????

 

[BlueBlue8]

Isn't this on the OPINION column???????

Yeah, an opinion for a working DPT..ya know someone with first hand experience.

 

[DancerFutureDPT]

Yes, but I know plenty of working DPTs who are not fearful at all of this.

 

[lee9786]

What determines the reimbursement value for PT services? Based upon what I've read, private insurance generally follows the CMS reimbursement value as a guide to determine what they will pay for PT services. So following this logic, if the CMS cuts PT reimbursement through this MPPR, than most likely private insurance will follow suit and do the same.

As with MotionDoc's example, if PT services were to be dropped altogether from the insurance scheme I mean system, who is paying for the fee-for-service model for PT services? Just like any other service-oriented business that doesn't have overinflated prices due to a third-party payment structure, the consumer market will determine the price for services based upon what they will pay directly for such services to meet the demand. When you are dealing directly with the payer, it's wise to look at the ability to pay thus the target market. What is the target market in outpatient PT? The geriatric population (most on a fixed income from SSC), injured workers, athletes (also PTs are competing with ATCs in this). How much discretionary income is there with this target group?

Also think about attitudes regarding copays. Currently people complain about a $20 copay. How much could PTs recieve for reimbursement in a free market without third party payment structures? Is that the way things are heading? Legislators have been postponing these Medicare cuts for years. There clearly is a problem though with a lack of financial resources. Has there been any solution presented which will prolong the longevity of the Medicare program? It looks as if the option that the legislators have been looking at, is decreasing reimbursement to healthcare providers. They are trying to reduce fraud and yada yada etc, but all you have to do is talk to PTs to understand how this inefficient beauracracy is unsustainable. Just look at the unemployment in this country. How is a underpopulated, unemployed, indepted workforce going to be able to support the social programs of Medicare, Social Security, Medicaid, etc...? My prediction is we won't. Where are the jobs in the future of this country? Government jobs? They suck up tax money and resources not produce them, but look at how many government jobs have been created in this recession.

Ask yourself when the axe eventually drops who is getting cut? Assume that PT is on the list which according to what has been presented looks to be the case. Take this reality along with the overinflated school loan debt that it takes to work as a PT. Then put yourself in a position where your attempting to obtain a $20 copay/payment for your PT services. In my mind it is a frightening reality. Maybe there's something I'm missing. I'd be glad to hear comments.

 

[mtm34]

The AMA will ensure that any physician fee cuts made will be made up- outpatient is how the physicians make the big bucks and there is no way they will allow a dwindle in their profits. The APTA is not anywhere near the power of the AMA but they will ride the coattails. Basically PT and out patient physician offices will be fine. PT is going to be even more crucial in keeping the cost of healthcare to seniors down in the future than it is now. Direct Access along with increased education and increased patient load causes for a change in the way the profession works. You can't have a DPT working one on one with patients day in day out- most likely more of check in at the beginning of the visit and maybe 10 minutes of one on one time for jt mobs and counseling things of that nature but there will be more aides and more techs much like there will be more PA's for the physicians. As long as you see 'physician fees' alongside physical therapy reimbursement PT will be just fine as long as big brother AMA is in the mix to hold court.
Simple supply and demand people- more people in the health care system, more people that will need PT than ever before= Demand (which in America equates to dollars and sustainability)

 

[BlueBlue8]

I am hopeful for private pay services especially if you can find the right clientele: athletes, older patients with expendable income, etc.

I know both a dermatologist and an ENT who is putting more energy/time/advertising into their cosmetic services namely botox for the former and nose jobs for the latter. Both doctors complained about a 10-20% discount in medicaid/medicare reimbursement, and they are considering not seeing these types of patients.

So I'm wondering if outpatient clinics are heading this way in the world of PT.

 

[eMotion29]

There are a couple of points that I think should be addressed in this conversation. The first is the issue of inevitability. Let me illustrate it this way. I recently received a newsletter from the Social Security Administration. The letter stated that the social security trust fund will be depleted by 2037. Interestingly enough, the following paragraph stated that a retired individual will still be able to collect $760.00 for every $1,000.00 invested into SS (if the fund is depleted and the country is bankrupt, how can we collect any money...but I digress). I can simply sit back and bemoan the fact that 27 years from now social security will be broke, or I can alternatively begin now to fight for change. I don't want to sit back and passively invest in a SS fund where the government squanders 24% of my investment. The only reason that outpatient PT services are where they are with regards to Medicare cuts is because groups like the APTA and individuals like you and me have stood up to protest unreasonable cuts. I encourage you to get involved. Write your senators, join your local PT organizations, get involved in the national debate.

Second, we need to address the dual issues of accessibility and affordability. My grandmother works for her state department of health. For years the department was headed up by health care professionals that understood how be cost efficient and provide optimal care. Now, the department is under new management (people with MBAs and no health care experience) who enact wasteful spending policies while cutting important policies like giving free TB shots to impoverished individuals and former inmates looking to get hired at a local chicken farm. Let's take this discussion to the national level. Tell me why a person can get admitted to the hospital and a panel of specialists will rack up a $50,000 bill on tests which may or may not even lead to a confirming diagnosis? Tell me why the same medicare that fronts the $50,000 bill wants to place ~$1800 cap/year on physical therapy services? How will the person with a lifelong, progressive neurological disease continue to function? Are the powers that be so far removed from the needs of it's constituents? As future health care professionals, we need to lead the debate on what constitutes medically necessary expenditures, the current cost of health care, and the role that PT can play in actually reducing long term health care spending.

The third issue I want to address is longevity. In 1906, there was a hurricane that damaged much of the southeast. Without getting too enamored with details, I want to point out that the local communities came together and worked to rebuild their homes and businesses. When the government attempted to intervene, the people said thanks but no thanks. Let's move forward to the crisis in New Orleans. The biggest debate that was going on at that time was why the government wasn't doing more or moving faster. Have we come to the point where we are so crippled by big government handouts that we can't function as a society without it. Let's say the third party payer system fails us. So what? Can we as health care providers tap into that rich heritage of American ingenuity, fortitude and courage and produce a business model that will reach our "target consumers" while ensuring a suitable profit. Maybe I'm an idealist, but I believe so...

 

[lee9786]

The AMA will ensure that any physician fee cuts made will be made up- outpatient is how the physicians make the big bucks and there is no way they will allow a dwindle in their profits. The APTA is not anywhere near the power of the AMA but they will ride the coattails. Basically PT and out patient physician offices will be fine. PT is going to be even more crucial in keeping the cost of healthcare to seniors down in the future than it is now. Direct Access along with increased education and increased patient load causes for a change in the way the profession works. You can't have a DPT working one on one with patients day in day out- most likely more of check in at the beginning of the visit and maybe 10 minutes of one on one time for jt mobs and counseling things of that nature but there will be more aides and more techs much like there will be more PA's for the physicians. As long as you see 'physician fees' alongside physical therapy reimbursement PT will be just fine as long as big brother AMA is in the mix to hold court.
Simple supply and demand people- more people in the health care system, more people that will need PT than ever before= Demand (which in America equates to dollars and sustainability)

The physician fee schedule is determined by the MEDPAC if I'm correct which is government. I'm sure if it was up to the AMA, they wouldn't have physical therapy tied in at all with their reimbursement structure. If you take away the POPTS, and give PTs third-party reimbursement for direct access, there is no financial incentive for the AMA to care what PT is doing. The APTA will be competing side by side with the AMA more than they are now. Since the AMA holds more political influence, fighting over the exponentially shrinking reimbursement pie will be difficult.

One positive note I do see as a possibility is the fact that Medicare payments could go so low to the point where Physicians won't accept payments. This would open up an opportunity for PTs to step in and provide a lower cost alternative for NMSK primary care. So if Medicare does still succeed to exist ten years from now, there could be an opportunity. The question is can the Medicare program stay afloat in this country?

Another thing to think about is the supply and demand concept. What determines demand for PT services? There may be a high need for the service, but if the ability to pay for that service isn't there one of two things happen. Either the service isn't provided because the cost is too high, or the cost of the service decreases to meet the ability to pay for it. Which one would it be in PT? We are already seeing a shortage of PTs, but the salary hasn't increased significantly over the decade. Why is that?

 

[lee9786]

There are a couple of points that I think should be addressed in this conversation. The first is the issue of inevitability. Let me illustrate it this way. I recently received a newsletter from the Social Security Administration. The letter stated that the social security trust fund will be depleted by 2037. Interestingly enough, the following paragraph stated that a retired individual will still be able to collect $760.00 for every $1,000.00 invested into SS (if the fund is depleted and the country is bankrupt, how can we collect any money...but I digress). I can simply sit back and bemoan the fact that 27 years from now social security will be broke, or I can alternatively begin now to fight for change. I don't want to sit back and passively invest in a SS fund where the government squanders 24% of my investment. The only reason that outpatient PT services are where they are with regards to Medicare cuts is because groups like the APTA and individuals like you and me have stood up to protest unreasonable cuts. I encourage you to get involved. Write your senators, join your local PT organizations, get involved in the national debate.

Second, we need to address the dual issues of accessibility and affordability. My grandmother works for her state department of health. For years the department was headed up by health care professionals that understood how be cost efficient and provide optimal care. Now, the department is under new management (people with MBAs and no health care experience) who enact wasteful spending policies while cutting important policies like giving free TB shots to impoverished individuals and former inmates looking to get hired at a local chicken farm. Let's take this discussion to the national level. Tell me why a person can get admitted to the hospital and a panel of specialists will rack up a $50,000 bill on tests which may or may not even lead to a confirming diagnosis? Tell me why the same medicare that fronts the $50,000 bill wants to place ~$1800 cap/year on physical therapy services? How will the person with a lifelong, progressive neurological disease continue to function? Are the powers that be so far removed from the needs of it's constituents? As future health care professionals, we need to lead the debate on what constitutes medically necessary expenditures, the current cost of health care, and the role that PT can play in actually reducing long term health care spending.

The third issue I want to address is longevity. In 1906, there was a hurricane that damaged much of the southeast. Without getting too enamored with details, I want to point out that the local communities came together and worked to rebuild their homes and businesses. When the government attempted to intervene, the people said thanks but no thanks. Let's move forward to the crisis in New Orleans. The biggest debate that was going on at that time was why the government wasn't doing more or moving faster. Have we come to the point where we are so crippled by big government handouts that we can't function as a society without it. Let's say the third party payer system fails us. So what? Can we as health care providers tap into that rich heritage of American ingenuity, fortitude and courage and produce a business model that will reach our "target consumers" while ensuring a suitable profit. Maybe I'm an idealist, but I believe so...

I'm all for getting the Government out of a lot of things. I think big government is why this is going to fail. I'll say that boldly because I don't see it going anywhere as our voter base is mostly comprised of these individuals with their hand out that don't want to see it go away. Our political leaders are weak and can only see to the next election. The majority of Americans ignore the facts and take the propaganda spilled out on CNN and Fox news as fact.

The fact that the insurance cartel just took over healthcare more than it already has with this healthcare bill has been a huge turnoff. If PT were to break from the insurance scheme altogether it would be a great thing in my mind. The problem is the cost of working in PT isn't based upon the free market. Imaging 150k in student loan debt making 25-30k/year. Not a good situation to be in.

 

[jbizzle]

Yes, but I know plenty of working DPTs who are not fearful at all of this.

Me too, and I know one who owns his own clinic who is not worried and told me to keep pursuing PT and offered me a job already after I graduate (little did he know I didn't get in). He gets direct access patients coming in all the time and some referals

 

[MuscleHead]

as a student about to enter a DPT program this Fall, articles like this scare the **** out of me...and infuriate me at the same time. where are the priorities in this country? its interesting how so many industries have plenty of money coming in...but somehow there isnt the money to sustain health care? pretty sure i would rather be able to walk on my own than drive a BMW.

 

[lee9786]

as a student about to enter a DPT program this Fall, articles like this scare the **** out of me...and infuriate me at the same time. where are the priorities in this country? its interesting how so many industries have plenty of money coming in...but somehow there isnt the money to sustain health care? pretty sure i would rather be able to walk on my own than drive a BMW.

I think what happened as everyone as a whole in this country got greedy. To get what they wanted they would do so on a promise. This credit got out of control to a point where people made irresponsible decisions. At some point though you have to pay it all back, and when the economy is consumer/ debt driven problems arise in doing so. When the people can't get jobs because of a consumer freeze, then they go on unemployment. When things don't get better, the government extends unemployment only to exacerbate the problem even more.

It is a shame that healthcare as a whole seems to be in a downward spiral. I think the problem arises when you have other people paying into a pool of money for others. I think a system that warrants personal responsibility thus a private health care pool for oneself and their family should have been the way to go. Simple demographics show that Medicare is going to be in a very tough position in the years ahead. You have a whole lot of beneficiaries with a lack of financial resources to serve them. Something has to give. I just haven't seen anything from our legislators that demonstrate that they have any clue about how to successfully deal with this issue. Or maybe they do have an idea, but know we won't like what needs to be done when the time comes.

 

[PTtoBe]

There may be a high need for the service, but if the ability to pay for that service isn't there one of two things happen. Either the service isn't provided because the cost is too high, or the cost of the service decreases to meet the ability to pay for it. Which one would it be in PT?

I think you answered your own question. As you said, there's a high need/demand for PT in the country, and really the world. Ask a person with plantar fasciitis or low back pain if they'd be willing to pay to make the pain go away for good. In most cases the answer will be yes, although the amount will vary with income and level of pain. More importantly, therapy is necessarily heavily integrated into the medical healing process at the hospital, subacute, and outpatient levels, and as such the service can't cease to be provided. A total knee or hip replacement without rehab would have disastrous results for many. In short, the demand for PT will always be there, even if there's less money available to pay for it.

So if the ability to pay for PT dwindles, the cost for the service is ratcheted down. Couple this with government-provided healthcare (where consumers pay for it through taxes) and what you end up with are a lot more patients with less profit-per-patient for healthcare providers. MTM logically envisioned a future where PTs spend only 15 min. or so with a pt. to do quick ROM/MMT/mobilizations to see where the pt is at and adjust their treatment. I think this is more or less where we're headed: PTs evaluate and prescribe, the aides and PTAs execute the treatment, PT checks in 5 days later for a Progress Note and to adjust the treatment as necessary, and eventually discharge. In fact, this is close to what a PTs profession has already evolved to in some settings.

So the day of a PT will be entirely evals, progress notes, discharges, and paperwork. Patients will spend most of their time with aides and PTAs than they'd like, but the system they created won't sustain anything more than that. You can see all of healthcare is moving in this direction...family physicians don't spend nearly as much one-on-one time with their patients as they used to. Healthcare as a whole will become less patient-centered and more driven by minimizing time on patients in order to maintain the overhead of huge medical facilities and the staff to run it. Medical staff become busier and more frazzled, patients get poorer care, we'll probably all end up still paying for it through taxes, and everyone loses.

On a side note, I've been disappointed with how aides appear to increasingly be used as cheap fill-ins for PTA/PT duties of exercising with patients that have muskuloskeletal or medical impairments. These are not professionally trained staff with any real knowledge of how different types of patients will respond to different types of exercise, and as such are liabilities to both their company and our patients. I think this is a natural consequence of the decreased availability of PTs and decreased Medicare reimbursement.

In the end, the consumers are the one with the most at stake, although they never seem to realize it until they're depending on a 17-yr old half their size to safely transfer them to a NuStep and then not overexert them.

But as far as us future PTs are concerned, there will be jobs waiting for us on the other side, and the pay will probably be roughly where it is right now or slightly more. No the compensation is not increasing as fast as tuition at the moment, but at the end of the day you'll be making at least a healthy (not substantial) living if you want to.