How physical therapists can thrive under health care (1)

Downloadable slide show at http://www.BulletproofPT.com

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How Physical Therapists Can Thrive Under Health Care Reform

August 20-21, 2011Orlando, Florida

Tim Richardson, [email protected]

The Florida Physical Therapists in Private Practice (FLPTPP) presents


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The Florida Physical Therapists in Private Practice (FLPTPP) presents

Armin Loges, PT

Chris Mulvey, PTTim Richardson, PT

Diane Hartely, PT

Eric Douglass, PT

Robert Dragan, PT

Stephen Trinque, PT

Tom Zeller, PT

Tricia Trinque, PT

mailto:[email protected]+




mailto:[email protected]
















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Can We Do Better?

• 47 million uninsured Americans.

• America spends more than any other country in the worlds, almost 17% of Gross Domestic Product (GDP), on healthcare.

• But, America ranks #37 in Quality and Fairness according to the World Health Organization (WHO). Click the link for the 2008 PBS Frontline documentary Sick Around The World.

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/?autoplay

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/?autoplay


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Can We Do Better?


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Can We Do Better?


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Can We Do Better?


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What is an Accountable Care Organization (ACO)?

The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by:

• Promoting accountability for the care of individual Medicare fee-for-service beneficiaries.

• Requiring coordinated care for all services provided to a population of people under Medicare Fee-For-Service.

• Encouraging investment in infrastructure and redesigned care processes in order to reduce the per-capita cost of healthcare.

Eligible providers, hospitals and suppliers may participate in the Shared Savings Program by creating or joining an Accountable Care Organization, also called an ACO. The ACO is expected to transition to population-based payment arrangements


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Section 3022 of the Affordable Care Act that was signed into law by President Barack Obama on March 23, 2010 requires the Centers for Medicare and Medicaid Services (CMS) to establish a Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.


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Risk & Reward


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ACO Quality MeasuresFive Domains

1. Patient/Care Giver Experience2. Care Coordination3. Patient Safety4. Preventative Health5. At-risk Population/ Frail Elderly


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ACO Quality Measures


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CMS is proposing to define the first quality performance period as beginning January 1, 2012, and ending December 31, 2012.

For the first year of the Shared Savings Program, CMS proposes to set the quality performance standard at the reporting level.


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The Physician Group Practice (PGP) Demonstration was the first pay-for-performance initiative for physicians under the Medicare program.

1. Billings Clinic, Billings, Montana2. Dartmouth-Hitchcock Clinic, Bedford, New Hampshire3. The Everett Clinic, Everett, Washington4. Forsyth Medical Group, Winston-Salem, North Carolina 5. Geisinger Health System, Danville, Pennsylvania 6. Marshfield Clinic, Marshfield, Wisconsin7. Middlesex Health System, Middletown, Connecticut 8. Park Nicollet Health Services, St. Louis Park, Minnesota 9. St. John’s Health System, Springfield, Missouri 10. University of Michigan Faculty Group Practice, Ann Arbor, Michigan


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There are three primary ways for an ACO to achieve savings on the care of the assigned Medicare population:

1. Reducing emergency room visits and hospital inpatient admissions.

2. Reducing the provision of specialty care for the assigned Medicare patient population

3. Reducing the provision of imaging and other special tests


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Preventing Avoidable Hospital Re-admissions

Preventable readmissions can occur because of... • Inadequate discharge planning• Inadequate post-discharge follow-up• Lack of coordination between inpatient and

outpatient healthcare teams.


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Smith et al reported on the discharge recommendations of 40 physical therapists treating 762 patients at a large, acute care hospital. Smith wanted to see how often the therapists’ recommendations were followed.

The therapists’ discharge recommendations were followed 83% of the time. There was a mismatch in PT recommendation and patient discharge location in 124 of 743 cases .

When the therapists’ recommendations were NOT followed, the patients were 2.9 times MORE likely to be readmitted than when the recommendations were followed.

The hospital had an 18% 30-day re-admission rate, which is consistent with the literature.


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What is an Accountable Care Organization (ACO)? Specialist Costs


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Overutilization of CAT scans: Double billing the Medicare program

Imaging Costs

http://www.nytimes.com/interactive/2011/06/17/us/hospital-ct-scans.html?ref=health


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Intervention Reimbursement Range of Estimated Charges

Lumbar spine radiography $50$204–286 (in network)$404–565 (out of network)

Lumbar spine computed tomography

$381 (without contrast) $459 (with contrast)

$1082–1517 (in network)$2091–2928 (out of network)

Lumbar spine magnetic resonance imaging

$715 (without contrast) $863 (with contrast)

$877–1226 (in network)$1762–2467 (out of network)


Imaging Costs


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How to Manage a Patient Population


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Epidemiology

The branch of medical science dealing with the transmission and control of disease and the mathematics of the collection, organization, and interpretation of numerical data, especially the analysis of population characteristics by inference from sampling.


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How to Manage a Patient PopulationPopulation health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

It is an approach to health that aims to improve the health of an entire population.

One major step in achieving this aim is to reduce health inequities among population groups.

Population health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, resource distribution, etc.

An important theme in population health is importance of social determinants of health and the relatively minor impact that medicine and healthcare have on improving health overall.

From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes“.


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How to Manage a Patient PopulationDiagnosis

The process the clinician uses to move progressively from a region of low clinical certainty to a region of high clinical certainty.

In low probability conditions, screening tests are used to generate diagnostic possibilities and to “rule out” improbable conditions.

In high probability conditions, diagnostic tests are used to confirm, or “rule in” likely conditions.

Both testing and treatment carry risk.


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How Are Physical Therapists Making Diagnoses?

• Self-Rated and Physical Characteristics

• Treatment Based Classification

• Pathological Conditions

• Psycho-Social Conditions


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Self Rated and Physical Characteristics Prevalence

“Fair” or “Poor” self-rated health 44%

Chronic Depression in Adults 6.7%

Generalized Anxiety in Adults 18.1%

Usual Gait Speed < 0.42m/s 25%

Rapid Gait Speed < 0.57m/s 25%

Three Chair Squats > 10sec. 24%

Any alcohol use 62%

> 5 medications 35%


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• ODI• SPADI


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How to Manage a Patient PopulationTreatment Based Classification Prevalence

Manipulation for LBP Group 35 - 45%

Stabilization for LBP Group 8 - 72%

Lumbar Traction for LBP Group 9 - 24%

Directional Preference for LBP Group 18 - 45%

Thoracic Manipulation for Neck Pain 54%

Thoracic Manipulation for Arm Pain 61%

Mobilization for Lateral Ankle Sprain 75%

Hip Joint Mobilization for Anterior Knee Pain 68%


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How to Manage a Patient PopulationPathology Prevalence

Ankle Fracture following Trauma 15%

Knee Fracture following Trauma 6%

Deep Vein Thrombosis in post-surgical patients varies

Carpal Tunnel Syndrome in patient with wrist pain/numbness 34%

Spinal Fracture following Trauma in Older People 0.5 - 3.0%

Community Acquired Pneumonia (CAP) 2 - 8%

Acute Stroke in Dizzy Patients in the Emergency Setting 25%

Hip Joint Mobilization for Anterior Knee Pain 68%


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Prediction of Community Acquired Pneumonia (CAP)

• Temperature > 100.04o

• Pulse > 100bpm• Crackles/Rales on auscultation• Decreased breath sounds on auscultation• No asthma

The clinician assigns one point for each of the findings that is present.

Clinical Decision Rules


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Prediction of Community Acquired Pneumonia (CAP)Prevalence of Pneumonia in Primary Care = 2%


How many variables are present?0 present 2% likely

1 present 3% likely

2 present 11% likely





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Prediction of Community Acquired Pneumonia (CAP)Prevalence of Pneumonia in the Emergency setting = 8%


How many variables are present?

0-1 present 8% likely

2-3 present 27% likely




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Lung Sounds: Normal

Lung Sounds: Crackles/Rales

Lung Sounds: Wheezing


http://www.rale.ca/media/bronchial.wav

http://www.rale.ca/media/crackles_a.wav

http://www.rale.ca/media/wheezing_a.wav


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Individual Findings Positive Likelihood Ratio (+LR)

Negative Likelihood Ratio (-LR)

Decreased Breath Sounds 3.7 0.7

Wheezing 3.8 0.66

Rhonchi 5.9 0.95


Pneumonia Decision Rule Positive Likelihood Ratio (+LR)

Negative Likelihood Ratio (-LR)

0 or 1 findings - 0.3

2 or 3 findings - -

4 or 5 findings 8.2 -

...compared with...


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Derive Sn, Sp, +LR, -LR with a 2x2 table

Need Pneumonia numbers


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How to Manage a Patient PopulationMcGee’s Bedside Estimates

Likelihood Ratio Estimated Probability Shift

0.1 - 45%

0.2 - 30%

0.3 - 25%

0.4 - 20%

0.5 - 15%

1 No change

2 +15%

3 +20%

4 +25%

5 +30%

6 +35%

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8 +40%

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10 + 45%


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Disruptive Innovation“The business models of health are frozen in the hospital and the doctors’ office. The path to fixing the system is to disrupt those models.”Clayton ChristensenThe Innovator’s Prescription

There are really three business model under one roof in the hospital:

1. Precision medicine that can be “Routinized”. The goal is to identify areas where automation of repetitive tasks can improve care and save costs. Example: Total Knee Replacements.

2. Intuitive medicine that requires highly trained specialists using costly diagnostic testing machines to discover the best treatment approach. Example: Gregory House, MD.

3. Empirical medicine is the costly trial-and-error realm of chronic disease management. Christensen predicts an increase in patient autonomy, self-diagnosis and self-care choices. The rise of social networks will feature prominently in this realm. Example: Outpatient Physical Therapy.


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Disruptive Innovation


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Disruptive Innovation

Primary care physicians will tend to disrupt the business practices of specialist physicians

Non-physician professionals, like Registered Nurses, Physical Therapists and Physicians Assistants, will tend to disrupt the business practices of primary care

physicians

Specialist physicians


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How Physical Therapists Can Drive Better Outcomes

• Exercise is generally NOT harmful. Power training.

• Increased, self-directed activity is essential to reducing disability.

• Promote activity: walking, yoga, running, lifting, resistance programs, Zumba, Pilates, gardening, golf, fishing.


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• Hurt ≠ Harm.

• Emotional/Mental factors may drive 30-55% of musculoskeletal outcomes.

• Behavioral training more important than Cognitive training


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Adequate physical activity is linked with important health outcomes…

• Reduced cardiovascular disease• Type 2 diabetes• Some cancers• Future falls risk• Osteoporotic fractures• Depression• Physical function scores on standardized self report

measures


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Behavior Change Assumptions

Education

Knowledge

Behavior Change



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Behavioral interventions MORE effective than educational interventions.

• Goal setting/contracting• Self-monitoring• Feedback – Functional Scales• Consequences/rewards• Exercise prescription• Cues


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Goals– Do single leg standing x 30sec. three times per day

to improve balance.Cues

– First thing in the morning do single leg standing x 30sec. in the kitchen while the coffee percolates.


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Educational/cognitive interventions LESS effective at promoting physical activity

• Targeting knowledge, attitudes or beliefs• Mass media (vs. individualized instruction).• Train-the-trainer models (vs. staff providing

interventions directly to patients). • Idiosyncratic provider interventions (vs. standardized

recommendations).


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“Medical Theater”

Real treatment effects/outcomes due to some aspect of the medical intervention other than the physiologic effect. NOT a placebo!

“A placebo is a substance or procedure…that is objectively without specific activity for the condition being treated…”


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What drives outcomes in addition to the intended treatment?

Dress: The white coast and stethoscopeLanguage: Medical jargon based in LatinDiagnosis and Expectation: The effect on functional status over time of a diagnosis of “disc degeneration”Cost: More costly medical treatments have a higher cost and a higher perceived benefitColor: Blue pill vs. Red pill study by Blackwell


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• Albuterol vs. Sham Acupuncture for Asthma (2011)

• Branded Analgesics for Headache (1981)

• Red pill vs. Blue Pill for Mood Alteration (1972)

• Internal Mammary Artery Ligation for Chest Pain (1959, 1960)


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Health Coaching

Hotspots by Atul Gawande, MD featuring Jeffrey Brenner, MD

New Yorker magazine article

Frontline “Hotspotters” Video

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

http://www.pbs.org/wgbh/pages/frontline/doctor-hotspot/




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The Six Sources of Influence


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How to Persuade your Patient

• Stone et al attempted to change college student sexual protection behavior.

• Lectured the students: “Use Condoms!” – didn’t work• Had college students make an educational video to teach high

school students about protected sex.• Technique worked.• 80% of the college students bought condoms immediately and

the amount of condoms purchased was greater than a control group.

• Technique known as Cognitive Dissonance.


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Critical Pathways of Care: Starbucks/Aetna Saves Money, Improves Outcomes



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Costs and ProductivityMetric Median

Charge per visit $164.26

Payment per visit (South Region) $85.18

Payment per visit (National) $94.77

Number of patient visits per hour 2.86

Payroll as a percent of income (includes Owner’s “replacement cost”) 65.6%

Number of visits per patient (single visit patients extracted) 11.6

Cancel/No-show rate 11.2%

Time to Cash 40 days

Payer Mix: Medicare 22.7%

Profit Margin 14.2%


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Structured Data

Structured data is another way of referring to data that is entered into a specific field as opposed to free text in a chart note.

60% of the narrative note data is lost to the EMR.


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Structured Data


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Structured Data


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Structured Data


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Structured Data


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Structured Data


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Structured Data


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Structured DataHistory Diagnosis Vital Signs Negative Findings Treatable

findings

Hydrocephalic Neuropathy

New onset Loss of Balance

BP (serial)158/89154/86174/85170/93150/75

No Medication Changes

Stiff neck: Cervical Rotation Right 50o

Left 44o

Pulse 71- 88bpm Dix-Hallpike Test neg. Spurling positive, bilateral

SpO2 97% Epley’s Maneuver neg.

Lung sounds clear, bilateral

Hoffman’s tests (UE) neg.

No falls status

h-HIT neg. bilateral


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Structured DataPatient Self-Report Impairment-level data

1/10 pain left knee“I’m not kneeling on the left knee because I’m afraid” AAROM (Supine) 0 – 98o

• Which structured data point is more predictive of the outcome?

• Which structured data point is predictive of future disablement?

• Which structured data point demonstrates Medical Neccesity for Physical Therapy to initiate a PT POC or to exceed the PT Cap using the –KX modifier?


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Structured Data


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Structured Data


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CAGE Rule for Alcoholism Screening

• An estimated 100 million Americans drink alcohol.

• 10% of those who drink have alcohol problems that adversely affect their lives and their families lives.

• The mortality rate of those who drink 6 or more drinks per day is 50% than matched controls.

• Alcohol is a major factor in suicides, homicides, violent crimes and motor vehicle accidents.

• Physicians are about to recognize, without decision aids, only about half of the problem drinkers they encounter.

• Physicians are even LESS likely to identify, without decision aids, alcohol problems in women and elderly people.

Decision Rules


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1. “Have you ever felt you ought to cut down on your drinking?”

2. “Have people annoyed you by criticizing your drinking?”

3. “Have you ever felt bad or guilty about your drinking?”

4. “Have you ever had a drink (eye opener) first thing in the morning to steady your nerves or get rid of a hangover?”

Decision Rules


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Decision Rules

CAGE Rule for Screening Patients for Alcohol Abuse

How many “yes” responses? Probability Shift Likelihood Ratio

0 present - 45% 0.13

= 1 present No change 1.5

= 2 present + 25% 4.5

= 3 present + 50% 13



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Decision RulesHINTS to Diagnose Stroke in Acute Vestibular Syndrome (vertigo, nystagmus, nausea, head motion intolerance, unsteady gait)

• Normal Horizontal Head Impulse Test• Nystagmus in different gaze positions• Test of Skew with prism crossover test of ocular alignment

Prevalence of Stroke: 25% of dizzy patients in the emergency setting are experiencing a stroke.

HINTS is Head-Impulse, Nystagmus, Test-of-Skew.

http://www.youtube.com/watch?v=CZXDNLLGG8k&feature=related





http://www.youtube.com/watch?v=-J170K7VAdA

http://www.youtube.com/watch?v=-J170K7VAdA


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Decision Rules

HINTS Decision Rule for Dizzy Patients

How many variables are present? Probability Shift Likelihood Ratio

0 present stroke diagnosis unlikely NA

> 1 present +50% chance of a stroke +LR = 25


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Decision Rules

• DVT risk and prevalence is increasing.• DVT and Pulmonary Embolism (PE) is “the most

common preventable cause of hospital death in the United States”.

• 2 million Americans develop DVTs every year and 200,000 die of the associated PE.

• Each year, over 25,000 people in England die from venous thromboembolism developed in hospital.

Screening for Deep Vein Thrombosis


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Decision Rules

Patient Safety Indicator Year Number of

EventsTotal Cases

Evaluated

Rate per

1,000Associated Mortality

% change in Rate (2005-

2007)

Post-operative pulmonary embolism

or deep vein thrombosis

2005 43,436 3,421,095 12.697 4,166

-14.51%

2006 46,640 3,360,843 13.877 3,942

2007 46,764 3,216,572 14.538 3,661

2005-2007 136,840 9,998,510 13.686 11,769



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Decision Rules

Patient Group DVT Incidence (%)

Medical patients 10-26

Major gynecological, urological, or general surgery 15–40

Neurosurgery 15–40

Stroke 11-75

Hip or knee surgery 40-60

Major trauma 40-80

Spinal cord injury 60-80

Critical care patients 15-80



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• Active cancer? • Bedridden recently >3 days or major surgery within four weeks? • Calf swelling >3cm compared to the other leg? • Collateral (non-varicose) superficial veins present? • Entire leg swollen?• Localized tenderness along the deep venous system? • Pitting edema, greater in the symptomatic leg? • Paralysis, paresis, or recent plaster immobilization of the lower extremity • Previously documented DVT? • Alternative diagnosis to DVT as likely or more likely?

Decision RulesScreening for Deep Vein Thrombosis (DVT)


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Number of Positive Findings Risk Classification Likelihood of DVT

<1 pt. Low risk 3%1-2 pts Medium Risk 17%> 2 pts High risk 75%

Decision Rules

Screening for Deep Vein Thrombosis (DVT)


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Test Question: “Do you believe that you should not do any activities that make your pain worse?”

Response Likelihood ratio Probability Shift

Patient answers “Yes” 34.88 + 50%

Patient answers “No” 0.18 - 30%

In one study of 80 patients, George estimates the population prevalence of elevated fear avoidance behaviors to be 37.5%.

Screening for Fear Avoidance BeliefsDecision Rules


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The largest single, modifiable factor affecting worker and our patients’ outcomes may be the psychosocial factor.

As stated by Waddell... “…fear of pain and what we do about it may be more disabling than pain itself.”



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Decision RulesScreening for Depression

• Prevalence of acute depression is 25% in Americans.• Depressed patients 3x more likely to be non-adherent

with their medical treatment.• Of the world’s ten leading causes of disability, five are

psychiatric/addictive conditions.• With appropriate treatment, 80% of people with

depression will recover fully.


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Screening for Depression

Ask your patient these questions:

“During the past month, have you often been bothered by feeling down, depressed or hopeless?”

AND

“During the past month, have you often been bothered by little interest or pleasure in doing things?”

Decision Rules


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Decision Rules

Screening for Depression

Number of “yes” responses Probability Shift

0 - 20%

1 + 20%

2 + 30%

Prevalence of acute depression is 25% in Americans.Prevalence of chronic depression is 6.7% in Americans


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Decision RulesPhysician Quality Reporting System

1. Health Information Technology: Adoption/Use of Electronic Medical Records (#124)2. Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological

Evaluation (#126)3. Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of

Footwear; Preventive Care and Screening (#127)4. Body Mass Index (BMI) Screening and Follow-up (#128)5. Documentation and Verification of Current Medications in the Medical Record (#130)6. Pain Assessment Prior to Initiation of Patient Treatment (#131) 7. Falls: Plan of Care (measure #154)8. Falls: Risk Assessment (#155)

The Affordable Care Act makes a number of changes to the Physician Quality Reporting System, including authorizing incentive payments through 2014 and requiring a penalty, beginning in 2015 for professionals who do not satisfactorily report.


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Decision RulesPhysician Quality Reporting System

In addition, physical therapists are eligible to report on a measures group related to back pain. If a physical therapist elects to participate based on this measures group, he or she must perform all the measures in this group. The back pain measures include: • Back Pain: Initial Visit (measure #148) • Back Pain: Physical Exam (measure #149) • Back Pain: Advice for Normal Activities (measure #150) • Back Pain: Advice Against Bed Rest (measure #151)

“Several of the proposed ACO quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System...”


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Decision RulesOttawa Rules for Ankle Fracture Following Trauma


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Decision RulesOttawa Rules for Knee Fracture Following Trauma


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Decision RulesScreening for Spinal Fracture


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Decision RulesCancer Screening in Lower Back Pain


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How Physical Therapists Can Do Better

Clinical Decision Support Tools

• Move away from “asking permission” from the physician to “making recommendations” to the physician.

• Knowing when not to treat is as important as knowing when to treat.• Maintain a list of health professions to refer patients to when indicated. • Maintain a high “index of suspicion” for pathology• Collect baseline data. Create systems. Push down data collection to

every person in the clinic.• Standardize your Examination. Screen low AND high risk populations.• Find patterns.• Follow-up


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How Physical Therapists Can Do BetterPopulation Health

Address population health through behavior and active exercise programs. Some possibilities might include:

• Smoking cessation• Alcohol/Drug screening• Adult weight loss• Childhood obesity• Stress reduction• Yoga• Pilates• Acupuncture• Massage therapy• Exercise boot camps• Group support programs (eg: depression)• Encourage patients to find a primary care provider


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How Physical Therapists Can Do Better

•ACOs may lower costs, improve quality•Physical therapists can address population health•Physical therapists can address behavioral health

• Physical therapists may need to alter patients’ and physicians’ expectations•Structured Data is a new type of documentation

• Clinical Decision Rules are a “Technological Disruptor” in Health Care...

...if we use them!


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Thank You

How physical therapists can thrive under health care (1)

Health & Medicine

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