Editor's note: the following is a sneak peek at research that will be featured as part of Physical Therapy's (PTJ's) special series on health services research, beginning with the December issue.
In an exploration of a payment area that could take on increasing prominence in physical therapy, researchers have found that Medicaid patients with low back pain (LBP) whose front-line treatment is provided by a physical therapist (PT) tend to generate lower costs over 1 year than patients who went to the emergency department (ED) or physician.
Though the study's authors describe the number as "few" by proportion—75 Medicaid enrollees used a PT as their entry point—analysis showed that patients who began with physical therapy generated an average per-patient 1-year cost of $335, compared with $533 for primary care and $900 for patients who used the ED as an entry to care. Results were e-published ahead of print in Physical Therapy (PTJ), the journal of APTA. The study's authors include Julie Fritz, PT, PhD, FAPTA, and Anne Thackeray, PT, PhD.
To conduct the research, authors analyzed care and expenditure data from 2,289 individuals in the University of Utah Health Plans "Healthy U" Medicaid program who received treatment for a complaint of LBP during 2012. Researchers separated the patients in terms of the setting in which they entered care—physical therapy, ED, primary care, or physical medicine and rehabilitation. They also looked at patients who did not enter by way of physical therapy but received physical therapy later, either within 14 days of the initial visit or 14 days or longer afterwards. Researchers also tracked the presence of comorbidities among all patients.
In the end, primary care was found to be the most common entry point for the patients, with 70.8% of the population beginning their LBP care in a family medicine, internal medicine, urgent care, or obstetrics/gynecology setting. EDs were the second most-used entry point (17.6%) followed by physical medicine and rehabilitation (3.9%), and physical therapy (3.3%). "Other settings"—orthopedic or neurosurgeon, chiropractic, pain medicine, etc.—were selected by 4.4%.
Regardless of the entry point, 20% of all patients received physical therapy at some point during the 1-year study period, with an average of 5.2 visits per patient. Of those patients who received physical therapy, 16.4% received physical therapy at entry, 19.5% received physical therapy after entry but within 14 days, and the remaining 65.1% received physical therapy at some point 14 or more days after entry.
Other findings about patients who received physical therapy:
Overall, the average cost for treatment of LBP over the 1-year study period was $626—less than the $900 average for patients who entered via the ED, but close to double the average costs associated with patients who went to a PT first. Authors noted that comorbidities—which occurred at a higher-than-average rate for the Medicaid patient studiedwere associated with higher costs.
Researchers found that the group who entered care through physical therapy "tended to be younger, healthier, and more likely to be female" than the overall sample. While their study did not assess reasons for selecting physical therapy, they believe it's a topic worth pursuing. "Considering the relevance of the choice of entry setting on outcomes and costs in this sample, further research exploring reasons for patients' choices could lead to strategies to promote more effective and less costly options such as physical therapy rather than relying on the ED for entry," they write.
While Medicaid enrollees may not make up a big portion of the physical therapy patient population at present, authors believe that the increases to the Medicaid rolls brought about the Affordable Care Act and the rise in the number of states that allow direct access to PTs (Utah is a direct access state) will mean that PTs could see this number grow in the near future. At least 1 state has taken the idea a step further; this summer Oregon adopted a change to its Medicaid provisions that lists physical therapy among the "first-choice" treatments for back pain.
But it's not just a matter of numbers, according to authors of the Utah study, who write that more work needs to be done to address patient and other stakeholder assumptions about which treatments are the most effective.
"Improving LBP care patterns for Medicaid recipients will require strategies addressing both system- and patient-level factors that drive ineffective and costly patterns," they write. "This may include everything from shifting hours of operation, educating patients and providers, and increasing the focus within physical therapy on providing self-management strategies for recurrent episodes and exacerbations. Knowledge of barriers and facilitators will be required … if effective strategies to promote more effective, less costly care patterns are to succeed."
A recent article in USA Today explores how injured professional athletes are developing an appetite for soup—or more precisely "The Soup" and other similar processes that involve injecting stem cells processed from the patient into an injured area. Proponents say it speeds healing and can help patients steer clear of surgery; detractors say it's unproven, unregulated, and maybe illegal.
Actually, "The Soup" is the brand name of 1 product, described as "a mixture of human cells that includes stem cells derived from a patient's own fat," available "for a minimum price of $15,000," according to USA Today. But The Soup is just 1 approach in what the article describes as an "exploding field" in sports medicine and health care overall, with the number of stem cell clinics in the US quadrupling over the past 5 years to nearly 200.
USA Today interviewed several athletes who claim that the stem cell therapies allowed them to rapidly heal from injuries such as rotator cuff and tendon tears. Former NFL running back Merril Hoge told USA Today that he received stem cell treatment for a ligament in his elbow that was "50% torn" and was able to avoid "a 6-month rehab process."
Doctors who administer the treatments are also interviewed for the story, one of whom is quoted as saying that the approach must be effective because professional athletes have so much at stake when seeking treatment. "They're going to do their research—them and their agents," physician Joseph Punta says. "They're not going to do something that's bogus and doesn't work."
Not so fast, say others in the story—including the US Food and Drug Administration (FDA), which has already issued a warning to one manufacturer that the stem cell concoction, even though derived from a patient's own tissues, is in fact a new drug and as such requires proper testing before approval. Other critics contend that regardless of the regulatory issues, there's a lack of research supporting the effectiveness of the treatments.
The controversy is not new. Last year, researchers published a paper questioning the ways in which professional athletes publicly promote stem cell therapies to imply "a sense of safety and efficacy even when one does not exist."
Want information on the role of stem cell treatments in physical therapy, as well as other advances in technologies that regenerate tissues? Check out APTA's webpage on Regenerative Rehabilitation. Resources include a podcast on "stem cell basics."
In news that may not be all that surprising to physical therapists (PTs) and physical therapist assistants (PTAs), the US Centers for Disease Control and Prevention (CDC) reports that among US adults 45 and older, the rate of total knee arthroplasty (TKA) surgeries nearly doubled between 2000 and 2010, to a rate of 55.4 per 10,000 individuals.
Rates of increase were different for men and women, with males experiencing an 86% increase and females reporting an increase of 99%, according to a CDC data brief (pdf) generated by the National Center for Health Statistics (NCHS). And as the frequency of the procedure has grown, the average age at which TKA takes place has dropped, from 68.9 in 2000 to 66.2 in 2010.
Among other findings in the report:
The report cites TKA as "the most frequently performed inpatient procedure" in 2010, with an estimated 693,400 procedures performed that year alone. TKA was also the top procedure in 2008 and 2009.
Although the CDC report did not speculate on the reasons for the rise in TKA procedures, some researchers have linked the frequency to an overall increase in the nation's obesity rates, while others have estimated that nearly one-third of all TKAs may be "inappropriate" given the presenting condition.
Visit PTNow for a clinical summary on rehabilitation after TKA and a guideline on appropriate use criteria for non-TKA treatment of knee osteoarthritis.
Forget about staying young at heart. For most Americans, simply having a cardiovascular system that isn't lapping them in the race to old age is a challenge, according to a new report that says 69 million US adults have a "heart age" that is, on average, 7 years older than their chronological age.
The findings were released in a "Vital Signs" report from the US Centers for Disease Control and Prevention (CDC). To arrive at a heart age, CDC calculated the age of a person’s cardiovascular system based on risk factors that include high blood pressure, cigarette smoking, diabetes status, and body mass index (BMI). CDC researchers used data collected from every US state and information from the Framingham Heart Study in what they describe as the first to provide population-level estimates of heart age.
Although the older heart age phenomenon was pervasive, the range of differences play out across demographic lines. Half of American men aged 30-74, for example, have an estimated heart age that is, on average, 8 years older. Among women in the same age range, 2 in 5 have an estimated heart age that is an average of 5 years older.
Similarly, while heart age exceeded actual age among all ethnic groups, the age difference was highest among African-American men and women, with an average 11-year gap. Geographically, Mississippi, West Virginia, Kentucky, Louisiana, and Alabama had the highest percentages of adults with a heart age 5 or more years over their actual age. Utah, Colorado, California, Hawaii, and Massachusetts had the fewest adults with a difference of 5 or more years.
Researchers acknowledge that the monitoring and control of individual cardiovascular disease (CVD) risk factors is key to improving overall public health, but they believe the concept of "heart age" might be a good way to get people to pay attention—and do something to lower their risk.
"Use of heart age might simplify risk communication and motivate more persons, especially younger persons, to adopt healthier lifestyles and better comply with recommended therapeutic interventions to prevent heart disease and stroke," authors write in the study used by the CDC. "Moreover, its use might support public health efforts in geographic areas most at risk for poor CVD outcomes and support the implementation of programs and policies that increase the availability of heart-healthy lifestyle options within communities."
The PT's important role in chronic disease was reemphasized at the 2015 APTA House of Delegates, which adopted an association position on Health Priorities for Populations and Individuals (RC 11-15). Want to learn more about the ways PTs can engage in cardiovascular disease management? Download this recorded webinar.
So what exactly is the physical therapist's (PT's) professional scope of practice, and how would you go about describing it as a definition rather than a list of things PTs do? Now's your chance to weigh in.
All APTA members are invited to provide input on the APTA Board of Directors' efforts to create a broad definition of the PT professional scope of practice. The idea behind the project is to create a global description of practice that aims to be an overall description rather than a set of procedures and functions.
Members can evaluate and comment on the draft scope and the guiding principles behind it by visiting an APTA webpage set aside for the survey. Deadline for responses is September 11. Send your completed surveys to Practice-Dept@apta.org.
A proposed change in how Medicare would reimburse for lower-limb prostheses is drawing mounting criticism from patients and stakeholder organizations—including APTA. According to the association, the proposals now being considered would negatively affect patients by "restrict[ing] the ability of a therapist to provide the appropriate medically necessary care if they are providing therapy to a patient who has received an ill-fitting, or non-customized prosthetic or component based on Medicare coverage policies."
In a letter submitted to the durable medical equipment administrative contractors (DME MACs), the association takes issue with a proposal developed by the DME MACS that would impose extensive restrictions on who could receive a lower-limb prosthesis, what kind (or kinds) of prosthesis they could get, and when and under which conditions Medicare would pay for the devices. Though the DME MACs contend that the changes are necessary to counteract steep rises in prosthetics expenditures among Medicare beneficiaries, critics including APTA believe the proposal ignores the realities of rehabilitation and shortchanges the importance of clinical judgment.
"APTA understands the difficult balance of providing quality care that is medically necessary while attempting to curtail costs," the association states in its letter. "However, this [local coverage determination] has the potential to result in lower quality of care while ultimately increasing costs. In the long run, costs could be higher to Medicare due to complications associated with prosthetics that were inappropriate for the patient due to restrictive requirements, provided untimely or not provided at all."
APTA's concerns about the proposal range from what it views as overly restrictive definitions of terms in some sections to a lack of clarity in others, and addresses provisions that the association feels would minimize the importance of the expert individualized determinations made by appropriate health care professionals.
Additional problematic areas of the proposal cited by APTA and other organizations include the potential for CMS to restrict patients to older-model artificial legs if the beneficiary has any form of mobility aid (such as a walker or cane) that they would use for limited purposes, and a requirement that the prosthesis must provide "the appearance of a natural gait." In its letter, APTA points out that "'Natural gait' is a subjective term—and potentially discriminatory, particularly when dealing with individuals with disabilities."
Last week, opponents of the proposal staged a protest at the headquarters of the US Department of Health and Human Services (HHS), an event that drew coverage by CNN and other news outlets. The protest effort received a boost from former Nebraska Senator Bob Kerrey, who himself has an amputation and was quoted in a press conference as saying that "this is as stupid a rule as I've ever seen," and that the rule "completely ignores what's going on with amputees."
The comment period on the proposed changes closed on August 31. CMS has not established a timeline on when any new rules would take effect, according to an article in Modern Healthcare.
US News and World Report is emphasizing the importance of physical therapy home exercise programs (HEPs) and connecting readers with APTA's "Find a PT" resource as a way to make a physical therapist (PT) "match" that can increase the likelihood of follow-though.
An August 31 article, titled "4 Ways to Stick to Your Physical Therapy 'Homework,'" uses real-life examples of individuals who kept up with the HEPs provided by their PTs as a springboard for a set of tips to help keep patients on track. The article also features comments from Jessica Schwartz, PT, DPT, CSCS, a member of the APTA Media Corps.
The basic idea, according to the article, is that "if you want the [physical therapy] treatment to work, it's important to follow your physical therapist's orders," which include exercises to be done at home. Schwartz is quoted as saying that her work "can only take [patients] so far," but that when patients do their home exercises, they're "going to hit this thing out of the park."
Among the 4 tips offered in the article is a suggestion that patients find a PT who is "well-matched" to the patient's personality and lifestyle, given that physical therapy tends to involve a lot of 1-on-1 time between the patient and the PT. To help find what Schwartz describes as "the right person, the right place for you," US News suggests readers check out APTA's "Find a PT" search service offered at the association's MoveForwardPT.com website.
In addition to finding the right PT, the article recommends that patients connect their HEPs with a "broader purpose" or ultimate activity goal, that they strategize time management to identify opportunities to do the exercises, and that they be honest with their PTs when they haven't met their HEP goals.
At MoveForwardPT.com, APTA's consumer-focused website, HEPs are regularly noted in the "Physical Therapist's Guide" series that explains the role of physical therapy in the treatment of various conditions.
Want to join APTA's Find a PT service? Follow these simple instructions to add your listing to the database.
Facebook, WebMD, PatientsLikeMe, Yelp, Angies List, HealthGrades ... sooner or later, the raters are gonna rate.
The question is, should you shake it off?
This month's PT in Motion magazine cover story, "Raters Gonna Rate: What's Your Best Response?" looks at the ins and outs of online rating systems consumers use to evaluate—and, increasingly, to choose—their health care providers, including physical therapists (PTs). PT in Motion Editor Donald Tepper combines an overview of current ratings trends with interviews of PTs who understand the power of online reviews and are taking proactive steps to address the issue.
The good news, according to the article, is that it's mostly good news: ratings tend to skew favorably, with patients eager to share their positive experiences with a health care provider or facility. But there can be bad news from time to time, and PTs should pay attention. "Raters Gonna Rate" also features advice from PTs on how to overcome negative reviews and take steps to reduce the chances of frequent online complaints.
"Raters Gonna Rate," is featured in the September issue of
PT in Motion. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.
With the official startup date looming and the last dry run complete, the Centers for Medicare and Medicaid Services (CMS) says that at least from its end of things, all systems are go.
In its latest summary (pdf) of end-to-end testing of ICD-10 codes in its reporting systems, CMS reported that the July 20-24 tests did not uncover any new issues with the fee-for-service claims processing systems, and that there were no claims rejections made "due to front-end CMS systems issues."
"Overall, participants … were able to successfully submit ICD-10 test claims and have them processed through Medicare billing systems," CMS states in its report. "The acceptance rate for July was similar to rates in January and April, but with an increase in the number of testers and claims submitted."
During the testing period, CMS received 29,286 claims, with an 87% acceptance rate. Of the claims rejected only 1.8% were rejected because of an invalid submission of an ICD-10 diagnosis or procedure code. Just over half the claims received—52.7%--were from professionals. Institutions supplied 40.9% of the claims, with suppliers submitted 6.4%.
The official start date for ICD-10 use remains October 1. APTA offers a recorded webinar, free to members, and an ICD-10 webpage that is being updated with resources to help physical therapists prepare for the changeover.
Researchers have completed what they describe as "the first comprehensive description" of foreign-educated physical therapists (FEPTs), and produced a snapshot that covers everything from regions-of-origin to why FEPTs decide to make the move, and which states and practice settings they arrive at once they do.
The email survey was sent to 9,334 FEPTs but focused only on those who had been licensed in the past 5 years. The final results were based on responses from 1,978 FEPTs—a 22.4% response rate. The report on the survey was e-published ahead of print in Physical Therapy (PTJ), the journal of APTA. The complete article is available for free to APTA members.
And, sure, PT in Motion News could report on the results in some standard way, but why do that when the highlights can be presented quiz-style for a change? Ready?
1. What's the overall estimated percentage of FEPTs in the US physical therapy workforce?
Answer: FEPTs account for an estimated 4.2% of the workforce, which means the correct answer is C. It's a figure that researchers say is similar to nurses (5.4%). By comparison, medical physicians have an estimated foreign-educated rate of 25.8%.
2. Rank in order, from highest to lowest, the most- to least-frequently cited countries or regions of educational origin for FEPTs in the survey.
D. Middle East
Answer: By quite a margin, the Philippines (49.2%) leads the way, followed by India (31.2%). The Middle East (3.6%) is next on this list, though it's fourth overall (Europe, in third place overall, comes in at 6.3%). Canada (1.8%) registered behind Asia (2.7%), but ahead of Africa (1.6%), South America (1.4%), and the Pacific Islands (1.3%). Correct answer: C,A,D,B.
3. Of the FEPT respondents, 92.1% said they had practiced physical therapy before coming to the US. What was the average number of years they practiced before moving?
Answer: There was some considerable variation here, but the average number of years FEPTs spent as physical therapists in another region was 5.5 years (correct answer: A). FEPTs educated in India reported the least amount of time (approximately 3.6 years); FEPTs from Africa had the highest number of pre-US years, with an 11.1 year average.
4. Which US practice setting was reported as the most common for FEPTs?
A. Hospital inpatient department
B. Home health
C. Assisted living
D. Skilled nursing, long-term care, or extended care
Answer: The most-frequently reported practice setting reported by FEPTs was in skilled nursing, long-term care, or extended care (32.2%,), followed by home health (20.4%), hospital inpatient (10.5%), PT-owned outpatient clinic (9.3%), non-PT owned outpatient clinic (8%), hospital outpatient department (7.8%), and assisted living facility (7%). "Other" was cited among 4.9% of respondents. That makes D the correct answer.
5. A total of 62.1% of all FEPT respondents were initially licensed in 1 of only 5 jurisdictions across the US. Rank the jurisdictions in order from highest to lowest.
D. New York
Answer: Turns out that New York leads the way by a significant stretch, with 32.7%, followed by Illinois (10.3%), Texas (7.1%), Florida (6.9%), and Michigan (5.1%). So for this question, the correct answer is D, B, E, A, C. New York was the jurisdiction most common among FEPTs educated in Asia (78.6%), while FEPTs educated in Africa were more likely to take their first US job in Illinois. Canada-educated FEPTs tended to begin their US practice in Texas. Regardless of jurisdiction, 71.1% of FEPTs reported that their first US job was in a metropolitan area (defined as a zip code in a county with a population over 250,000).
6. What was the most-frequently cited reason for immigrating to the US?
A. Advanced education or training
B. To be with a spouse of family
C. Better working conditions
D. Higher wages or benefits
Answer: In the end, higher wages (26%) beat out an interest in advanced training (20.4%) to be the top reason for the move (correct answer: D). The ability to practice physical therapy at an advanced level was third (14.8%), followed by better working conditions (13%). Being with a spouse or family was in fifth place (10.5%), edging out "adventure or experience in a new culture" (10.2%). Only 1% cited "improved personal safety" as the reason for the move.
APTA has joined the Federation of State Boards of Physical Therapy (FSBPT), the Foreign Credentialing Commission on Physical Therapy (FCCPT), and APTA's Section on Health Policy and Administration (known as HPA: The Catalyst) in the creation of an online course that covers the health care delivery system in the US. The course, to be offered by Duke University, is designed to help PTs educated and trained outside the US overcome hurdles resulting from cultural differences and achieve a smoother and quicker transition to stateside practice.
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