Vol. 20 • Issue 5
• Page 10
On Feb. 9, physical therapists from all over the nation gathered at the world-famous Mandalay Bay in Las Vegas for the American Board of Physical Therapy Specialists (ABPTS) Ceremony for Recognition of Clinical Specialists. The recognition event saw 835 therapists become newly certified clinical specialists.
"Since 1985, when the first three clinical specialists were certified, there has been a substantial increase in physical therapists who pursue specialist certification each year," R. Scott Ward, PT, PhD, president of APTA, said. During those 24 years, a total of 8,408 physical therapists have become certified in seven specialty areas: cardiovascular and pulmonary, clinical electrophysiology, geriatrics, neurology, orthopedics, pediatrics and sports. The year 2009 will mark the first time PTs can sit for a Women's Health certification.
Keynote speaker Patty Sheets, PT, DPT, NCS, told the audience she was honored to be chosen by the ABPTS to speak about the importance of evidence-based practice. "My comments this evening are actually about leadership," said Dr. Sheets, who has been a board-certified clinical specialist in neurologic physical therapy since 1994.
Obtaining professional and post-professional degrees from The Program in Physical Therapy at Washington University in St. Louis, Dr. Sheets has served on the Neurological Specialty Council and ABPTS. Currently, she is an adjunct faculty member at Washington University and practices in central Illinois.
The theme of Dr. Sheets' speech was "Leading Your Village in Raising Your Community.""I believe that implementing evidence-based practice in physical therapy is not an impossible dream," she stated. "If we simplify the job description of physical therapists, then they will simplify their practice...Let's be sure we are holding our colleagues at a level of performance that [leads to] the depth of performance our patients deserve."
APTA Unveils New Brand
With the largest CSM gathering (more than 8,200 professionals) converging on Las Vegas for this year's conference, the stage was set for attendees to witness a crucial moment in the ongoing transition of the PT profession. APTA did not disappoint, unveiling its new branding campaign at a ceremony in the Palm Foyer of the Mandalay Bay Resort & Casino.
"Move Forward: Physical Therapy Brings Motion to Life" endeavors to position physical therapists as the leading experts in human motion for the 21st century. APTA hopes to position not only its members but all physical therapists as specialists who can help improve mobility and quality of life without the expense and pain of surgery or side effects of prescription medication.
"This is a very exciting time with the launch of our new brand, and the opportunity to teach physical therapists how to use [the brand]," said APTA President R. Scott Ward, PT, PhD.
Dr. Ward added that while the brand was under the APTA banner, the campaign was aimed at advancing the profession of physical therapy more so than the organization. Also speaking at the event were Brian Ellis and Debbie Myers of CRT-Tanaka, a public relations firm who helped APTA plan and publicize the campaign.
"When people hear "brand," they often associate it with a logo or symbol," said Ellis, "but this brand is about creating a better connection with consumers, raising the perception of the profession and motivating professionals." A short video with a theme of "You Are My Hero"-a collection of patients' tributes to their physical therapists-addressed not only the movement benefits of physical therapy, but also the value of having someone who came to be a trusted friend at a patient's most vulnerable time.
"Those who can't move lose their freedom," said Myers. "But this is what you represent-a chance to regain what has been lost."
Taking a Legislative Look
Legislative and infringement issues may seem difficult to monitor for physical therapy professionals who just want to focus on providing the best care for their patients. But these factors can have a significant impact on physical therapy practice, which the APTA recognizes by employing a diligent government affairs staff to advocate for the profession. Three members of that staff, Justin Moore, PT, DPT; Angela Chasteen and Justin Elliott, presented "Current Political Topics Forum: From the Statehouse to Capitol Hill," on Feb. 10.
"We will spend the next hour and a half walking through a number of health policy issues affecting our profession," opened Dr. Moore, vice president, government and payment advocacy. "It has been a very active day in Washington-they just passed the economic stimulus bill in the Senate this morning. In fact, we are only five weeks removed from the inauguration of the 111th Congress and I can honestly say that during my time in DC, I have never seen things happen so quickly."
The demographics of this congress include the most women ever seated and an increased Democratic majority in both the House and Senate, he added. "Health care was an election mandate in November-there is a feeling in Washington that they need to do something about this industry."
Two of the primary issues pertaining to PT on a national level are Medicare direct access and repeal of the therapy cap. "The trouble with direct access is opposition from physician groups, especially the American Academy of Orthopedic Surgeons," related Dr. Moore. "The opposition to a therapy cap repeal is primarily economic."
Chasteen, associate director of state government affairs, also discussed state issues. The political landscape includes two physical therapists newly elected to be representatives in Missouri and Wisconsin, she noted. "In addition, this fiscal environment is being affected by the economic recession, slow revenue growth and the fact many states are facing budget deficits. Policy trends include health care reform, retail health clinics, scope of study practice commissions and mandated benefit review."
Elliott, director of state government affairs, later discussed infringement issues with the session attendees. This is a potential concern with regard to several professions, including occupational therapy, massage therapy, recreational therapy, O&P and athletic training. APTA is also keeping an eye on the lobbying efforts of chiropractors, who in recent years have sought both to expand their scope of practice and introduce manipulation prohibitions against physical therapists. "Legislative attempts regarding one or the other can be expected in several states during the course of 2009," noted Elliott.
-Brian W. Ferrie
Assessing PT Market Demand
On Feb. 10, Lynn Steffes, PT, and Bridget Morehouse, MPT, MBA, spoke with PTs on how to accurately assess the market in the session "PT-Who Needs It? Exposing & Forecasting Market Demand for Physical Therapy Services."
"We are facing tremendous economic uncertainty. Fear of the unknown is the greatest fear businesses and the greater population faces," said Steffes.
Take a look at what population you are serving, she told PTs. Is your clientele young or old, men or women? Pay attention to what market demographics are telling you, she said. "Census data is available and you should be looking at it."
In 2010 there will be more than 100,000 people in the U.S. over 100 years old. And in this new economy, uninsured people will become insured through government plans. PTs need to think about what that means to their business, Steffes added. "Suddenly, the way we practice is affected by the economy. What can we do to be proactive?" she asked.
Responses ranged from having sales on services and extending practice hours to advertising businesses and bundling services. Some struggling practices are getting by through contracting their services to another area, such as outpatient services, Steffes disclosed.
Private practices have an advantage in this current economy because there is change in the market and private practices are agile, Morehouse noted.
PTs should collect information on their competitors as well as market trends on an annual basis. One way to analyze the market is through identifying all "alternatives" to physical therapy.
"PTs tend to look at competitors as only other PT practices," said Steffes, "but people who are paying out-of-pocket might use massage therapy because it has a perception of being less expensive and they can control how many times they go."
Once you identify these alternatives, collect their marketing materials, assess their strengths (i.e., expertise, convenience, location) and identify their weaknesses (i.e., scheduling limitations, short-term success, ). Then identify your practice's strengths and weaknesses. Steffes and Morehouse suggest communicating strengths to referral sources and consumers; developing strategies to address internal weaknesses and using market and clinic data to forecast trends.
"We have to start thinking of solutions," to get patients in the door, Steffes advised.
Strategies for Combating POPTS
The APTA keeps a watchful eye on the legislative strategies states can use to fight encroachment of physician-owned physical therapy practices (POPTS). But there are other ways to stop what many therapists see as a major cause thwarting the autonomy of the PT profession.
Peter J. McMenamin, PT, MS, OCS, and Brian J. Tovin, PT, DPT, presented "Combatting POPTS: Legislative and Non-Legislative Strategies for Every PT" on Feb. 11.
The profession's ability to combat POPTS through legislative and legal means is directly related to its survival as an autonomous profession, McMenamin said.
"Can PTs have a viable and independent business model as part of Vision 2020?" he asked. "The interest is there-within eight years we have seen a complete reversal of educational programs in this direction, from 20 percent of programs offering the DPT to 93 percent today. So it is market-driven. Direct access is also making progress, with full direct access in 14 states and provisional DA in 31," he said.
PTs are also increasingly becoming practitioners of choice for a more consumer-driven health care economy. "Ninety percent of consumers in our studies have a favorable impression of physical therapy and said they would be more likely to return to therapy if needed."
The one Vision 2020 goal that is lagging is PT's grip on autonomy, thanks to POPTS that are allowed to not only exist but prosper."Our profession won't survive without a new social-political-economic-business structure of an autonomous profession," McMenamin said. "A shortage of PTs is driving salaries higher while reimbursements are stagnating. We simply can't continue like this until 2020."
Strategies states are attempting to use to ban POPTS include laws against referral-for-profit (RFP), fee-splitting provisions for owners of practices, and professional corporation law, which is still a theory to deal with POPTS, McMenamin said.
POPTS are banned in South Carolina, Delaware and Missouri. All three states have language in their state practice acts that effectively bans POPTS; in SC, it is illegal for PTs to work for a POPTS. On the other hand, POPTS are deemed legal in Alabama, Tennessee and Rhode Island. McMenamin said in some of these cases, POPTS earned the right to exist in a state's practice act by essentially bartering direct access-physicians in the state backed direct access language in the PT practice act in exchange for the right to own PT practices if they chose.
"Many physicians assume that in states where they are allowed to own a POPTS, it will at some point become illegal, but they are willing to continue owning until that risk becomes reality," he said.
Preparing for Battle
State chapters should never attempt to "go it alone" when developing a plan to eliminate RFPs.
"It has to be a chapter-wide effort, and you have to have your full board committed to it," McMenamin stressed. "Everyone involved must fully understand their practice act implications, and have a war chest to fight with." Other important steps include:
Establishing a POPTS task force;
Developing an educational mission for the chapter to informabout POPTS;
Developing a legal team with a lawyer to work for the chapter;
Creating a lobbying team for the chapter;
Conducting a SWOT analysis on PT autonomy to determine where support for/against POPTS lies;
Scrutinizing the language in the state practice act on fee-splitting prohibitions, direct access and licensure rules;
Building a base of state private practice PTs who can campaign on fighting POPTS.
PTs should exert more influence in their states on therapists who work for POPTS, McMenamin said. But he made one thing clear. "Don't in any case go negative on PTs in your state who may work for POPTS. You have to develop a mobilization of all parties involved, including those PTs. You need to line up known and trusted allies on this cause, all the way down to the fence-sitters."
Proponents of POPTS-mainly the physicians who run them and the therapists who work for them-will often argue in their defense, said Dr. Tovin. "You hear all kinds of reasons-POPTS are one-stop shops for patients, they afford better communication between doctors and therapists, they are more cost-effective, they are good learning environments for therapists, and on and on.
One key is to encourage educators to stop their affiliations with POPTS for clinicals if they can, Dr. Tovin said. Physicans who own POPTS shouldn't be preferred lecturers, and students in their last semesters should be encouraged to try to avoid working for POPTS.The important thing to remember is that the profession still controls its own success, said Dr. Tovin. "Eliminating POPTS would have more of an effect on the profession's control than direct access does," he said.
Lecture Challenges the Diagnostic Method
Are therapists ready to take on the diagnostic role?
Mary Massery, PT, DPT, of Massery Physical Therapy in Glenview, IL, posed this question to those who attended her Linda Crane Memorial Lecture, "The Patient Puzzle: Piecing It Together," on Feb. 10.
When the APTA achieves its 2020 vision, physical therapists will be autonomous practitioners and the practitioners of choice for motor impairments. To help prepare, Dr. Massery presented the challenge of incorporating the less obvious pieces-the cardiovascular/pulmonary, integument/fascial, and internal organs systems-with the obvious pieces, the musculoskeletal and neuromuscular systems, in every motor evaluation and examination order to discriminate between the cause and the consequence of the impairment. She also argued that the cardiovascular/pulmonary system is often what ties the patient puzzle together and should be a part of every motor assessment.
"We need to prove that we will dig deep to find the 'real problem,' not take the easy road," Dr. Massery said.
The goals of her lecture included presenting a broader view of motor assessment that systematically includes the whole body, looking beyond the obvious musculoskeletal and neuromuscular systems, discussing the role of the cardiovascular/pulmonary systems in the assessment of motor dysfunction, and stating the case that multi-system evaluations should be the standard of practice for autonomous practitioners who are truly ready to be the practitioners of choice in the future.
She presented a little boy named Danny, now 15, as her diagnostic dilemma. His original complaint as a child was immobility of the trunk and spine. At first, Dr. Massery thought his issues were musculoskeletal. But further investigation proved that Danny's situation was much more complicated than initially thought.
Born 34 weeks early at 4 pounds, Danny had incomplete differentiation between his trachea and esophagus, sub-glottal stenosis and esophageal atresia.
By age 9, he had had 34 surgeries. It was determined that restrictions secondary to surgical scarring had caused musculoskeletal restrictions which limited his lung growth, which in turn reduced his neuromuscular movement strategies and caused issues such as trunk restriction that limited his extension.
"I use Danny's case to illustrate that anything we think is just a musculoskeletal issue is never ever a single system. We weren't born with single systems. We were born with systems that interact."
Are We There Yet?
For the past 12 years, the Pauline Cerasoli Lecture has been held to honor its namesake, an accomplished physical therapist who at the 1996 Combined Sections Meeting was attacked by an unknown assailant and left permanently injured.
This year's honoree was Bella J. May, PT, EdD, FAPTA, an adjunct professor at California State University in Sacramento. Unlike many preceding lecturers, Dr. May admitted she was not well-acquainted with Cerasoli, but that she'd found they shared many similarities. "Both of us look at problem as puzzles waiting to be solved."
Dr. May discussed the evolution of the PT profession throughout her career, spanning an impressive 55 years. When she started, PTs needed a prescription to take patients. Diagnosis and direct access were not even mentioned, and private practice was nearly non-existent. "Obviously, the evolution has been considerable," summarized Dr. May. "We've reached a point that a professional doctorate is an entry-level degree in the field."
Vision 2020 endeavors to take the profession to a whole new standard of access and autonomy, one that Dr. May stressed will be easier to attain with greater recognition form consumers. "How are [physical therapists] viewed?" she asked. "Outsiders still control access to our services."
The goal, Dr. May insisted, should be to work with physicians in lieu of working for them. The expansion of educational curriculum into teaching research and marketing has in part led to the ability of DPTs to examine, diagnose and develop plans of care for their patients. The question for educators, Dr. May said, becomes to what extent are they responsible for leading the next generation of PTs into these advances. Aside from teaching function and movement, today's educator is also responsible for leading research and marketing education, she said.
Dr. May spoke of the prognoses issued by many experts, who believe that technology is advancing so rapidly that many universities may be rendered obsolete in the coming decades. "Can we afford to use 20th century methods to teach our 21st century students?" she asked. "If we don't embrace the changes of the 21st century, we risk losing our best and our brightest."
Dr. May took the audience on a hypothetical trip to a PT school of the year 2025-a university serving as a specialized hub for a national PT curriculum. "We will enjoy communications between several nations-continuity between centers of excellence," predicted Dr. May.
In conclusion, Dr. May attempted to answer the title question of her lecture. "Are we there yet?" she asked. "Of course not. In fact, we may never get there-learning is a continuous journey."
Medicare, Private Insurance: They've Got Issues
It was a lot of ground to cover in just an hour and 45 minutes. Gayle Lee, JD, Roshunda Drummond-Dye, Esq., and Carmen Elliott, MS, presented "Emerging Issues in Medicare, Medicaid and Private Insurance on Feb. 10.
Lee first addressed the pending changes to the Centers for Medicare and Medicaid Services, which are somewhat on hold due to leadership issues. "Activities at CMS and HHS are obviously suspended because we still do not have a Secretary of Health chosen," Lee said.
"It has been determined that the current payment system for health care is just not sustainable," she added. "Accordingto new projections Medicare will now become insolvent by the year 2016, not 2019 as previously predicted. So it is clear CMS is looking at payment systems with an eye for change."
Lee noted that of the $4.07 billion paid out in outpatient therapy services in CY 2006, PT services accounted for 75 percent of that amount. In fact, after a low of outpatient PT expenditures in 1999 following the institution of the cap on outpatient therapy, PT payouts rebounded with gains each year up until 2006, she pointed out.
"CY 2000 also saw a major growth in PTs in private practice according to payments," Lee said. "That is why it is important for us to explain our importance to policy makers in this area."
One helpful factor is a marked decrease in paid claims in error rates to Medicare. The reduction is largely due to more education on the matter, she said. The biggest problem was insufficient documentation on timed codes and missing certifications when PTs billed Medicare. The drop in errors has helped keep costs down and successful claims going up.
Lee also touched on the status of the fee schedule, and feels Congressional action will take place to keep the physician fee schedule from enduring more cuts. "We can't imagine such a drastic amount would be allowed to take effect," she said. At the current rate, by 2015 Medicare would see a 40 percent drop in payments if action is not taken on the Sustainable Growth Rate formula used to calculate the fee schedule.
On the therapy cap, Lee noted that APTA is involved with two studies, one short-term and one long-term, on how CMS can identify alternatives to the Medicare cap on outpatient therapy. Data has yet to be gathered on either study but Lee said that depending on the results, "we could see something radically different from what we have now." Currently the cap is set at $1,840 for OT services and $1,840 for PT and speech therapy combined.
Medicaid is facing its own challenges to implement changes, Drummond-Dye said. She touched on some actions that would improve PT coverage and reimbursement under Medicaid, including establishing PT as a mandated health benefit under the Medicaid and State Children's Health Insurance Program (s-CHIP); creating minimum documentation requirements for PT services; mandating federal definitions of "qualified providers of PT services;" and ensuring proper reimbursement rates for PT services in each state.
Elliott outlined trends in private insurance reimbursement and what PT can do to help itself not lose out in an ever-narrowing window of payment opportunities.
"Consumers are beginning to assume a huge share of the risk for their own health care and providers know it," Elliott said. "They are becoming savvy shoppers for insurance, and they are looking for competitively priced services and quality outcomes."
Conversely, employers are shifting more risks to their employees. More than 60 percent of workers are still covered by health benefits offered by the firm they work for, she said.
Payers are now more likely to raise premiums and reduce medical claims costs where they can. Payers also are emphasizing more consumer-driven products such as highdeductible health plans and health savings accounts, she said.
National industry trends show employer-sponsored health insurance is decreasing and that underinsured and uninsured groups are growing.
The result? "The power of consumerism is driving the health care market, especially in this economy," Elliott said. Since they are being asked to pay more out of pocket for their health insurance, consumers will comparison-shop for those who offer the best outcomes for the lowest cost.
There is an impact on physical therapy that the profession must recognize, she said. Opportunities for PT in this economic climate include educating patients on lifestyle changes, contracting directly with employer groups, decreasing reliability on third-party payers if possible, tracking market trend data and payer activity, and stepping up advertising and good marketing.
"Health care is a business whether we like it or not," Elliott said.
Driving to Develop PT Leaders
As this profession seeks to enhance its recognition in the health care field, PTs and PTAs nationwide can help by letting others know why physical therapy matters. So "Revving Your Leadership Engine" represented one of the more intriguing educational sessions offered on Feb. 10.
Presented by Janet Bezner, PT, PhD, Z. Annette Iglarsh, PT, PhD, and Jennifer Wilson, PT, MBA, the session drew a crowd of PT professionals, including many who already held some type of leadership position at their respective facilities. Wilson stated some objectives: 1) isolate the essential differences between managers and leaders, and 2) review effective leadership styles.
"Managers tend to focus inward," she related. "They look inside the company and into each individual. Leaders, on the other hand, focus outward. They look at the competition, at the future and at alternative routes forward." The speaker asked audience members to raise their hands in response to whether they considered themselves managers or leaders.
"We believe physical therapists can be effective managers," said Wilson. "We also believe physical therapists are and can be effective leaders." She added that what it takes to develop managers may inhibit leaders.
Dr. Bezner introduced two objectives: 3) to explore opportunities for more vibrant leadership in physical therapy, and 4) to discuss values associated with individual leadership. Physical therapists are leaders because many core values of the profession, such as accountability, altruism, compassion, integrity, duty and social responsibility, equate to characteristics of leadership. There are four levels of leadership, she added, including personal, interpersonal, managerial and organizational.
"Leaders need to commit to a core set of values while at the same time question the methods taken to achieve them," Dr. Bezner explained. "It's not always easy to question fundamental things about our organizations, but it is necessary."
Dr. Iglarsh presented a fifth session objective: to self-assess leadership capacity and development needs. "I think for years we thought that if people weren't born leaders, they couldn't learn to be leaders," she said. "But people can learn and the first step is looking at yourself-you're the only person you can control."
• LAMP--The Institute for Leadership in Physical Therapy, sponsored by the HPA Section, will present "Becoming the Autonomous Professional of Choice," May 1-3 in Pittsburgh, PA. For more information visit www.aptahpa.org.
-Brian W. Ferrie
Cultural Standards in Home Care
It's all about color, according to Tonya Yvette Miller, PT, DPT, of Harrisburg, PA, and Jennifer Walsh, PT, DPT, of Lewisburg, PA.
The lecturers, who presented "Managing Diversity in Home Care," meant personality color profile, which describes the ways in which we perceive and learn. Attendees determined their own from four options by answering a few worksheet questions.
Whichever method you use to define your personality, knowing how you work, learn and interact is imperative to understanding how to deal with your diverse coworkers and clients. In the home health setting, patients' quirks and preferences may come out even more since you're on their territory.
"Our patients are all going to be different types of people...a cookie-cutter style is not going to work," Dr. Walsh said.
They advise therapists to take into account eight characteristics that involve the dimensions of diversity: age, race, gender, sexual orientation, ethnicity, mental and physical activity, religion and socioeconomic status. After learning these components of their clients, they can begin structuring patient care to include cultural competency.
Cultivation of cultural competence is not something therapists should do when the mood strikes them. It's actually required by the Culturally and Linguistically Appropriate Service Standards (CLAS), developed by the United States Department of Health and Human Services, which apply to any institution or facility receiving payment by Medicare or Medicaid. These guidelines ensure that health care needs are delivered in a manner consistent with the individual's cultural and linguistic background.
There are 14 CLAS standards, four of which are mandatory. The first three involve hiring a diverse work staff and providing education that is culturally appropriate. Standards 4 through 7 are required and necessitate providing language assistance at all points of contact in a timely manner. This includes providing written and verbal notices of a patient's right to receive language assistance and supplying interpretive and bilingual services. The remaining guidelines include involving linguistic and culturally appropriate services in a strategic plan in addition to the mission statement of your facility.
To learn more about the CLAS standards, visit www.omhrc.gov/templates