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  • Veteran and Emerging Physical Therapy Leaders Speak Out

    What's the difference between an emerging physical therapy leader and a well-established one?

    Not much—at least when it comes to love for their work and their vision of the profession’s future. (Apologies if you were expecting a punchline.)

    For its December issue, PT in Motion magazine posed an identical set of questions about the physical therapy profession to 2 seemingly different groups: this year's cohort of Catherine Worthingham Fellows of APTA (FAPTAs), and the 2019 class of APTA Emerging Leaders nominated by their chapter or section. Answers from the physical therapists (PTs) and physical therapist assistants (PTAs) tell the story of a profession that embraces its transformative potential but is clear-eyed about the challenges standing in the way.

    Questions posed ranged from the personal ("What was the best piece of career advice you ever received?") to the arguably unlikely ("If you had the undivided attention of Congress for 10 minutes to educate lawmakers about something related to physical therapy, what would you say?"), and points between. The answers, at times, were equally far-ranging.

    At other times, however, a seeming consensus emerged. Most respondents, for example, felt that today's younger generation of PTs and PTAs are better at establishing a healthy work-life balance. Additionally, the seasoned professionals and the relative newcomers generally share a perception that the cost of physical therapy education is making it difficult to create a more diverse physical therapy workforce.

    And, while not articulated in every response, it becomes clear as the article unfolds that nearly every responding PT and PTA places a strong value in the potential for dedicated professionals to make a difference for both individual patients and the physical therapy profession as a whole.

    Interviewee Gammon Earhart, PT, PhD, FAPTA, sees that value as a source of optimism.

    "Our biggest strength is our people. I am inspired by the talented, dedicated leaders in all areas of our profession who are passionate advocates for physical therapy," she said. "My optimism for the future comes not only from these current leaders, but equally from up-and-coming students and early-career professionals who bring great energy and new ideas."

    "Generation Rap: Veteran and Emerging Leaders Speak Out" is featured in the December issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA.

    Study: For Children With Autism, Yoga Improves Motor Skills, May Buffer 'Cascading' Effects

    In this review: Creative Yoga Intervention Improves Motor and Imitation Skills of Children With Autism Spectrum Disorder
    (PTJ, November 2019 )

    The message
    There's mounting evidence that motor impairments are particularly prevalent among children with autism spectrum disorder (ASD), but research on how to address these impairments is scant. Authors of a new study believe they may have hit upon an approach: physical therapist-led "creative yoga," which they say improved both gross motor skills and the ability to imitate movement patterns among children with ASD. Those gains, they believe, could play a role in improving social communication and behavioral abilities.

    The study
    Researchers divided 24 children with ASD, ages 5 to 13, into 2 groups: the first group received an 8-week "academic intervention" that focused on reading, arts, crafts, and other "sedentary activities usually practiced within school settings"; the second group participated in an 8-week yoga intervention, led by a physical therapist (PT), that "was made fun and creative through the use of songs, stories, games, and props." The children were assessed for motor skills using the Bruininks-Oseretsky Test of Motor Performance-2nd Edition (BOT-2) at baseline and after completion of the programs, and tested for imitation skills at 3 points (baseline, midpoint, completion) using a researcher-created instrument. Sessions were conducted 4 times a week for 8 weeks, divided into 2 expert-led sessions lasting 40 to 45 minutes per week and 2 parent-led sessions lasting 20 to 25 minutes per week.

    Participants included in the study had a confirmed ASD diagnosis and showed social communication delays. All scored at average or below on the BOT-2 at baseline, and the groups were matched for baseline mobility scores as well as demographic, IQ, and other characteristics.

    APTA members Maninderjit Kaur, PT, and Anjana Bhat, PT, coauthored the study.

    Findings

    • After 8 weeks, the yoga group improved subtest scores for gross motor performance and bilateral coordination, whereas the academic group showed no statistically significant improvements in these areas.
    • The academic group improved scores related to fine motor precision and integration, but not so the yoga group, which recorded no statistically relevant changes.
    • Imitation skills improved for both groups, but at different points: the yoga group began showing improvements in imitation skills by the midpoint assessment, while the academic group's improvements didn't register significant change until the last assessment.
    • Among child-specific factors such as age, autism severity, and IQ, the only element that seemed to correlate to improvement in scores was IQ: in the academic group, children with higher IQs tended to achieve larger individual gains in imitation skills, while in the yoga program, children with lower IQs were the cohort that achieved larger individual gains in imitation (specifically, pose imitation).

    Why it matters
    A growing body of evidence suggests that children with ASD also tend to experience motor impairments of balance, postural control, gait, and coordination, as well as worse dexterity skills than do children with typical development (TD). In fact, authors write, researchers have estimated that children with ASD typically display motor development that is consistent with children half their age. Deficits in the ability to imitate demonstrated behaviors or movements are also associated with ASD.

    The concern, according to authors, is the possibility that these impairments could have "cascading effects on the social, communication, and cognitive development of children with ASD."

    "Given the evidence for motor impairments and their broader impact on social communication development," authors write, "there is a clear need to devise interventions that could offer opportunities to improve both motor skills and their use in developing social communication skills in children with ASD."

    More from the study
    Authors were surprised that the yoga group didn't report any improvements in balance, but they speculate that the unchanged BOT-2 scores may be related to the test's reliance on a mix of static and movement-based activities, as opposed to the yoga classes' focus solely on static balance. Additionally, they write, the BOT-2's balance subtest includes assessments with and without visual input, whereas the yoga classes consistently used visual input to help children hold poses.

    As for the academic group's improvements in fine motor skills, the effect sizes were relatively small, but researchers believe that may be due to the fact that most of the children were already engaged in similar activities in their school settings, creating a "smaller scope for improvement."

    Keep in mind…
    The study population was small and heterogenous, and the training duration was relatively short. Additionally, researchers weren't able to assess the long-term effects of the classes.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.  

    Getting a Handle on the Fee Schedule, Part 2: 4 Things to Know About the KX Modifier, MIPS, Dry Needling, and Revocation

    The final 2020 physician fee schedule rule released by the US Centers for Medicare and Medicaid Services (CMS) is generating lots of discussion among physical therapists (PTs), physical therapist assistants (PTAs), and other stakeholders for its potential future payment cuts and application of the PTA modifier, but there are other provisions in the rule that deserve attention too.

    Here are 4 things that you should know about the rule, set to go into effect on January 1, that might've been overshadowed by the headline-grabbing payment news. (For a more in-depth summary, check out APTA's regulatory review on the rule, and read part 1 of this PT in Motion News series, which covers the proposed cuts and PTA modifier)

    1. The Medicare payment threshold for outpatient therapy services will get a slight increase in 2020.
    The payment threshold system replaced the cap on therapy services under Medicare in 2018. As with the former therapy caps, the threshold amount is adjusted annually, and for 2020 the amount for the required addition of the KX modifier increases from $2,040 to $2,080 for physical therapy and speech-language pathology combined. (The occupational therapy threshold amount will be raised to $2,080 as well.) The threshold for targeted medical review will remain unchanged, at $3,000.

    2. Dry needling has codes—but that doesn't necessarily translate into payment.
    The final rule adds to the fee schedule 2 dry needling codes—one for needle insertions without injections in 1-2 muscles, and another for insertions in 3 or more muscles—but CMS has assigned a "noncovered" status to them, meaning that original (fee for service) Medicare won't pay for it. If you're working with any other insurance, including Medicare Advantage, check to see if they will pay for dry needling under the new codes. Also: Under Medicare fee for service, because these codes are "noncovered," an Advance Beneficiary Notice is not required, but it can be voluntarily provided (and is recommended).

    3. The Merit-based Incentive Payment System (MIPS) is getting tweaked, including its "opt in" offering.
    CMS is adjusting MIPS to include more measures such as diabetic foot and ankle care; falls screening and plan of care; elder maltreatment screen and follow-up plan; dementia: cognitive assessment, functional status assessment, and functional status change for patients with neck impairment; among others. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments. The MIPS scoring system also will be changed, with the required final score to receive a neutral payment adjustment increasing to 45 in 2020, and then to 60 points for the 2021 payment year.

    The MIPS program will also continue to offer an "opt in" program for PTs meeting some but not all of the MIPS participation requirements. Details on how that system works are available through the CMS Quality Payment Program website. Questions about MIPS? Contact us at advocacy@apta.org.

    4. CMS will have wider authority to deny or revoke.
    The final rule grants CMS an expanded ability to deny or revoke a physician’s or other eligible professional's Medicare enrollment if the provider has been subject to action from a state oversight board, a federal or state health care program, an independent review organization, "or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care." The action must be related to unprofessional conduct that resulted in patient harm, and CMS allows itself leeway in issuing revocations or denials based on the nature of patient harm, the professional's conduct, and the number and types of disciplinary actions taken.

    Visit APTA's Physician Fee Schedule webpage for summaries, links to online learning opportunities, and resources documenting APTA's advocacy efforts. Also, join APTA regulatory experts for "The Changing Landscape of Federal Payment, Coverage, and Coding Policies," a live Q&A session set for December 10, 1:00 pm–2:00 pm ET. Download a prerecorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the fee schedule, MIPS, TRICARE, and more.

    Getting a Handle on the Fee Schedule: 6 Things to Know About the New PTA Modifier and Estimated 2021 Cut

    The physical therapy profession can breathe a little easier after convincing the US Centers for Medicare and Medicaid Services (CMS) to back off from some of its more troubling proposals around work done by physical therapist assistants (PTAs) in the final 2020 Medicare Physician Fee Schedule (PFS). But the rule still includes policies that are cause for concern for many in the physical therapy community: notably, a planned cut that's estimated to reduce payment to physical therapists (PTs) by 8% in 2021, as well as a system that will eventually pay less for services delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA).

    In short, the 2020 PFS is a big deal. And at more than 2,400 pages, it's also just plain big, with several major components that affect PTs and PTAs in both good and bad ways, and plenty of context behind the details.

    You can read the entire rule to see for yourself, but before you do, here are 6 concepts that can help you understand what the profession is facing when it comes to the PTA modifier and estimated reimbursement cut in 2021.

    1. The application of the PTA and OTA modifiers were required by law—and will be broadly applied.
    The seeds that grew into the CMS rule requiring the use of modifiers were planted in 2018, when Congress passed (and the President signed) the Bipartisan Budget Act. The law required CMS to establish a system to denote when outpatient physical or occupational therapy services were furnished "in whole or in part" by a PTA or OTA, and beginning in 2022, to use that system to reimburse services at 85% when that "in whole or in part" line was crossed. The requirement applies to payments for physical therapy in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.

    2. The modifier system could have been a lot worse than what's in the final rule. APTA members were a big reason for the improvement.
    When CMS proposed how the modifiers would be used—"CO" for OTAs and "CQ" for PTAs—it forwarded an needlessly complicated system that threatened patient care and ignored the realities of PT practice (this PT in Motion News story outlines the problems with the proposed rule from APTA's perspective).

    APTA members, association staff, and other organizations pushed back hard by way of thousands of responses to the agency. CMS took notice, and while it hung on to its "de minimis" standard that the codes must be used when 10% or more of the service is delivered by a PTA or OTA, it backed away from many of the more problematic elements of its proposed plan. This is how the modifier process will work:

    • The CQ or CO modifier is required to be affixed to the claim line of the service alongside the respective GP or GO therapy modifier. Claims that aren't paired appropriately will be rejected.
    • The CQ/CO modifier doesn't apply if all units of a procedure code were furnished entirely by the therapist. The modifier requirement does apply when all units of the procedures code were furnished entirely by the PTA or OTA.
    • Only the minutes that the PTA spends independent of the PT count toward the 10% standard.
    • The 10% standard is applied to each billed unit of a timed code (as opposed to all billed units of a timed code as CMS originally proposed), and the system allows for 2 separate claim lines to identify where the CQ/CO modifier does and does not apply.

    Need more information? Join APTA for a live Q and A session on the modifier system on December 3, and prep for the event by reviewing a pre-recorded presentation now available. And keep an eye out for a quick guide to the CQ modifier coming soon to apta.org.

    3. The 8% cut is an estimate based on an attempt to maintain "budget neutrality” and is proposed for January 1, 2021.
    There are 2 main concepts at the heart of the planned 8% cut: the complex nature of relative value units (RVU), and the idea that in order to provide additional money to 1 area in the fee schedule, CMS must pull money from other areas (budget neutrality).

    RVUs are the basic unit of payment in the feel schedule, and they're established by way of a formula that involves values for work, practice expense (PE), and malpractice (MP), adjusted for geographic costs variations and multiplied by a conversion factor (CF). In the final 2020 fee schedule, CMS sets out a plan to increase work values for office and outpatient evaluation and management (E/M) codes, mostly used by physicians. That adjustment would raise overall RVUs for E/M services.

    The problem is that as far as CMS is concerned, giving several codes more money means giving other codes less. CMS' approach—strongly opposed by APTA and organizations representing 35 other professions facing cuts—is to simply devalue elements that are used to calculate RVUs in other areas. The agency asserts that it can't say with certainty that the estimated cuts will be the reality of payment in 2021 because it's waiting to see how other budget adjustments might affect the fee schedule's overall bottom line in 2021.

    4. Opposition to the RVU plan was far-ranging, strong—and largely ignored by CMS.
    The physical therapy profession wasn't singled out for a cut to pay for increased E/M reimbursement. Among the 36 professions affected, estimated cuts include a 7% decrease for emergency medicine, a 7% cut to anesthesiology, a 6% reduction for audiology, and 9% and 6% drops in payment for chiropractors and clinical social workers, respectively. CMS was flooded with messages opposing the cuts, including a letter initiated by APTA that was signed by 55 members of Congress. In its final rule, CMS briefly acknowledged the opposition and said it will address the criticisms in future rulemaking.

    5. APTA is aggressively fighting the cut, and all options are on the table.
    APTA is evaluating its advocacy options and refining its strategy for addressing the cut. We already know that any approach must involve working with other affected professions as well as mobilizing individual APTA members to add their voices to a grassroots campaign to let CMS know how the cuts could decimate care and put patients at risk.

    In fact, the effort has already begun. Visit the APTA action center to send a message opposing the 8% cut to your representatives on Capitol Hill—it only takes 2 minutes.

    6. APTA wants you to be prepared for what's coming soon.
    While the 8% cut remains an unsettled issue, there are plenty of elements of the 2020 fee schedule that will begin in January. The association and its regulatory affairs staff have already created several resources, with more on the way. Available now:

    APTA Regulatory Review: Final Physician Fee Schedule for 2020. The big picture, more on the CQ modifier and estimated cut, plus an overview of other elements in the PFS, including the Merit-based Incentive Payment System (MIPS), KX modifiers, remote monitoring, dry needling, and more.

    Live Q and A on CQ modifier, December 3, 12 Noon (ET). Download a pre-recorded presentation and submit your questions in advance for a detailed discussion focused on the new PTA code modifier.

    Live Q and A: The Changing Landscape of Federal Payment, Coverage, and Coding Policies, December 10, 1:00 pm – 2:00 pm. Download a pre-recorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the PFS, MIPS, TRICARE, and more.

    Insider Intel: PFS, MIPS, and more. A recording of a November 20 phone-in session with APTA regulatory affairs staff that touched on a wide range of payment topics, many related to the PFS.

    Information on the updated KX modifier thresholds and exceptions. The 2020 PFS includes a slight increase in the limits on therapy provided before the KX modifier is applied. Learn more here.

    Coming soon: a written guide on how to apply the CQ modifier, a webpage devoted to the 2020 Medicare changes, a 2020 multiple procedure payment reduction (MPPR) and sequestration fee schedule calculator, advocacy information on fighting the 8% cut, and more.

    CMS Rule on Hospital Price Transparency Sets the Stage for Major Shift in Public Access to Charges for Services

    In this review: Medicare and Medicaid Programs: Price Transparency Requirements for Hospitals to Make Standard Charges Public (final rule)
    Effective date: January 1, 2021
    CMS fact sheet

    The big picture: Hospitals will face more stringent requirements to disclose charges for items and services—including physical therapy—in a consumer-friendly, online form. Hospitals aren't happy about it.
    A final rule from the US Centers for Medicare and Medicaid Services (CMS) makes it clear that the agency will move ahead in its efforts to make hospital cost data more accessible to consumers. Beginning January 1, 2021, hospitals will be required to share a much more detailed range of charges, including gross charges, charges negotiated with a third-party payer, charges for cash payment from individuals, and minimum and maximum negotiated charges. The publicly accessible data must cover at least 300 services that patients can schedule in advance—known as "shoppable" services—and while hospitals have some leeway as to which service charges are included, they are required to lists charges for a core set of 70 services, including physical therapy, specifically therapeutic exercise (CPT 97110).

    The American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, and the Children's Hospital Association announced that they will challenge the final rule in court, writing in a joint statement that the rule "will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care delivery."

    Notable in the final rule

    The total number of disclosed services must be at least 300. If a hospital doesn't offer 1 or more of the 70 required services, it must substitute an additional shoppable service so that the total list equals at least 300 services.

    Listings must be easy-to-understand, presented in a "machine readable" format, and updated annually. In addition to the charge data being available for free on a public website, the lists must be in formats that can be "read" by computers (as opposed to pdf files, for example), and must use clear language in descriptions of services, including information that makes it easy to identify the particular hospital location associated with each listed service.

    The definition of "standard charge" is broad. Under the new rule, the "standard charges" that must be shared include cash prices, charges negotiated with individual payers, and de-identified minimum and maximum charges.

    Billing codes must be included. Listings must include relevant codes such as Current Procedural Terminology codes, Healthcare Common Procedure Coding System codes, and diagnostic-related group codes, among others.

    The rule will require health insurers to be more transparent, too. The rule extends to group health plans and health insurers, which will be required to allow public access to out-of-pocket cost information for all covered items and services, as well as to payment rates for both in and out-of-network providers.

    Does Everyone Have a Unique Muscle Activation 'Fingerprint?' Researchers Say Yes

    In this review: Individuals have unique muscle activation signatures as revealed during gait and pedaling
    (Journal of Applied Physiology, October 2019 )

    The message
    It's no secret that people move differently, but researchers who carefully tracked muscle movements of study participants during exercise think the differences may go even deeper than variation in movement styles. Their conclusion: humans possess muscle activation "signatures" that are as unique to each individual as fingerprints or iris structure. Not only could these patterns be used to identify an individual, they write, but finding a person's activation strategies could help to identify the potential for future musculoskeletal problems, and better tailor treatments to individual patient needs.

    The study
    Researchers analyzed movement patterns of 53 individuals using surface electromyography (EMG) on their legs as they pedaled on a stationary bicycle and walked on a treadmill. Using a machine learning protocol, authors of the study tracked activation patterns from 8 muscles of the right leg: the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), gastrocnemius lateralis (GL), gastrocnemius medialis (GM), soleus (SOL), tibialis anterior (TA), and biceps femoris-long head (BF). They used the data to establish unique muscle activation signatures recorded during an initial session. Participants then returned for a second round of the same activities between 1 and 41 days after the first (average, 13 days), allowing researchers to evaluate the similarities between activation patterns observed at each session.

    Participants were in good health. Most were male (77%), with an average age of 23.1 years and average BMI of 23.2 for males and 21 for females.

    Findings

    • Researchers found "substantial" variability in activation patterns among individuals, especially in the RF, GL, BF, and SOL muscles, with the same types of variability recorded on both days of activity.
    • The machine learning system was able to identify individual muscle activation patterns during the first session with a high degree of accuracy, particularly when more of the tracked muscles were factored into the mix. The classification rate was just over 99% for pedaling and 98.86% for treadmill gait.
    • Recognition rates were nearly as accurate when focused on the second session, where accuracy was 89.80% for 7 muscles in pedaling, and 86.20% for 7 muscles during walking. Authors of the study think the differences between the first and second sessions are due to variations in placement of the EMG sensors, but they believe that given the highly similar results, the differences in placement only strengthen their conclusions.
    • The RF, GM, GL and SOL muscles provided the best recognition data for pedaling, while the TA and BF muscles were tied strongly to better recognition data related to gait.

    Why it matters
    Earlier studies have established that movement patterns such as gait can be consistently linked with individuals—a kind of signature—but those studies stopped short of an examination of identifying the muscle activation strategies that may (or may not) influence the movement pattern. Authors of the EMG study believe theirs is the first to look into activation itself as a biomarker.

    Although they call for further study, authors believe that individual muscle activation signatures may have "specific mechanical effects on the musculoskeletal system" and could help identify individuals who are at greater risk of musculoskeletal disorders. For example, they write, the activation patterns of the GM, GL, and SOL muscles tended to vary significantly between individuals; because these muscles are attached to the Achilles tendon in different fascicle bundles, "different activation strategies might induce unique load patterns of load distribution within the Achilles tendon, with some strategies being more likely to lead to tendon problems."

    More from the study
    Authors didn't land on a single explanation for why muscle activation patterns might be individualized, but they write that both "optimal feedback control" and "good enough" theories of motor control could be at play in activation signatures.

    Activation patterns may be consistent with the optimal feedback control theory in that "it is possible that each individual optimizes their movement with the muscle activation strategies that are best, given that individual's mechanical and/or neural restraints," they write. On the other hand, they add, it's also possible that the signatures develop according to the "good-enough" concept, "through motor exploration, experience, and training, leading to habitual rather than optimal strategies." It's a debate that likely won't be settled without "retrospective studies on large cohorts or longitudinal studies performed at different lifespans," authors note.

    Keep in mind…
    The study population was small, and homogenous. While the homogeneity was intentional to tease out the accuracy of the machine learning process, the approach limited researchers' ability to identify potential motor control theories at play, and whether at least some of the activation strategies are innate.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    New APTA Campaign Makes Membership Personal—And Offers Prizes

    At APTA, it's always been about individual members working together to support shared values. That's the concept at the heart of a new membership campaign that builds on connections—and offers rewards to members who make them.

    APTA's "ONE by ONE" campaign, launched in October, makes membership personal by encouraging current members to recruit their fellow physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy students to join the association. Every time they recruit a new or returning member, they're entered into a monthly drawing for a free year of APTA membership. And if a member is able to recruit 5 or more new members by the campaign's end on September 30, 2020, she or he is entered to win 1 of 5 iPads that will be given away in October 2020.

    But that's not all: If a new member also joins an APTA section, the recruiting member receives an additional entry in the monthly free membership drawing, and all new members recruited through ONE by ONE are entered into a monthly drawing for APTA’s Passport to Learning, which provides access to the association's continuing education offerings in the APTA Learning Center. There's even a prize for the participating section that experiences the largest year-over-year growth rate during the campaign. All the details can be found on the ONE by ONE webpage, including a toolkit that gives you everything you need to join the campaign.

    APTA member Christel Johnson, PT, MPT, from Texas, was among the first to win free APTA membership. She's thrilled to get a break on dues, of course, but is quick to point to the bigger picture.

    "I believe in APTA and what it stands for, and I appreciate how it works to support this profession that I love," Johnson said. "I speak with all of my colleagues, residents, and students, to make sure they understand all that APTA does for us and the importance of supporting the organization through membership."

    The APTA ONE by ONE campaign runs through September 30, 2020.

    The Good Stuff: Members and the Profession in the Media, November 2019

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Getting soldiers back in shape: Kevin Houck, PT, DPT, recounts his experiences providing physical therapy to soldiers in the Middle East and the US. (Sharon, Pennsylvania Herald)

    Don't get uptight (quads): Rachel Tavel PT, DPT, offers stretching and relief techniques to help counter tight quadriceps. (Men's Health)

    Home is where the PT is: Jay Shaver, PT, makes house calls. (Kalispell, Montana, Daily Inter Lake)

    Falls prevention: Alex Anderson, SPT, discusses the importance of falls screening for adults 55 and older. (WHSV3 News, Harrisonburg, Virginia)

    Hospital-YMCA partnership: Becky Geren, PT, explains the physical therapy benefits of a new partnership between a local hospital and YMCA. (Chattanooga, Tennessee, Times Free Press)

    Thumb thing to think about: John Gallucci, PT, DPT, affirms that yes, "text thumb" is an actual injury, and provides tips on easing the discomfort.(Yahoo! Lifestyle)

    Making exercise habit-forming: Catherine Hoell, PT, DPT, shares her approach to helping her patients make exercise a part of their routines. (CapeCod.com)

    Quotable: "I want to be a patient advocate. I try to provide my patients with opportunities to improve their quality of life." -Ian Lonich, PT, DPT, who specializes in neurologic physical therapy. (Washington, Pennsylvania Observer-Reporter)

    Taping it for granted? Nick DiSarro, PT, DPT, peels back the real from the hype when it comes to kinesiology tape. (Parade)

    Spina bifida and e-stim: Gerti Motavalli, PT, outlines the benefits she has observed in using electrical stimulation therapy in treating children with spina bifida. (13 KRCG News, Columbia, Missouri)

    Advice for the hot-to-trot: Michael Conlon, PT, shares a few pointers to help get people ready to participate in post-Thanksgiving "Turkey Trot" runs. (NBC Better)

    Quotable: "I’m still interested in physical therapy. I get the magazines – it’s part of my life. You never get out of it!" Gertrude Schwarz, PT, who at 100 is the oldest living graduate of New York University's physical therapy program, on her love for her profession. (NYU News)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    APTA Cosponsored Study: Direct Access to Physical Therapy for LBP Saves Money, Lowers Utilization Better When It’s Unrestricted

    In this review: Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain
    (e-published ahead of print in PTJ, November 2019 )

    The message
    Does unrestricted direct access to a physical therapist (PT) make a difference compared with "provisional" direct access systems that include restrictions such as visit limits and referral requirements for specific interventions? A new analysis of insurance claims records from nearly 60,000 adults across the US says yes.

    The study, cosponsored by APTA, reveals that for patients with new-onset low back pain (LBP), seeing a PT first in states with unrestricted direct access resulted in lower health care costs and use compared with patients seeking care in provisional access states. And the differences don't end there: researchers found that patients in provisional access states who saw a PT first tended to incur higher costs than those who saw a primary care provider (PCP) first, while data from unrestricted direct access states showed relatively equal, if not slightly lower, costs for seeing a PT first compared with PCPs.

    The study
    Researchers reviewed private and Medicare Advantage insurance claims from 59,670 adults with new-onset LBP between 2008 and 2013 to explore health care cost and utilization from 2 perspectives: first, in terms of differences between patients who saw a PT first for LBP in states with unrestricted direct access versus those who sought PT care in states with provisional direct access provisions; and, second, in terms of differences between patients who saw a PT first versus those whose first meeting was with a PCP.

    The deidentified data was provided by OptumLabs®, which worked collaboratively with APTA and UnitedHealthcare to produce this and 2 other research articles related to access to PTs first for LBP. Authors of this study included APTA member Christine McDonough, PT, PhD.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, no patients diagnosed with neoplasm 12 months prior and 3 months after the first visit, and insurance enrollment for at least 12 months before and after the index date), nearly 98% initially met with a PCP. Overall, more women than men sought care for LBP, with around 21% of all patients reporting prior physical therapy use. Among patients who sought treatment from a PCP, experience with physical therapy was much lower—about 2.1%.
    • Among patients who saw a PT first, those in provisional-access states recorded 31% more physician visits and had 58% higher odds of having imaging in the first 30 days of the index visit, compared with patients from unrestricted states.
    • Average 30-day costs were lowest for patients in unrestricted states who saw a PT first for LBP, at $511. The next-to-lowest costs were associated with patients who saw a PCP first in unrestricted-access states ($556), followed by patients in provisional-access states whose first visit was with a PCP ($632). The highest costs were for patients in provisional-access states whose index visit was with a PT, at $726. After 90 days, the rankings shifted, but only slightly: seeing a PT first in a provisional-access state was associated with the highest costs ($1,269), followed by index visits with a PCP in provisional-access states ($1,046), PT-first visits in unrestricted states ($1,032), and PCP-first visits in unrestricted states ($948).
    • Patients in provisional-access states who saw a PT first averaged LBP-related costs that were 19% higher than PCP-first patients at 30 days. It was a different story in unrestricted-access states, where patients who visited a PT first averaged costs that were 4% lower than PCP-first patient costs, a difference that authors call "insignificant."

    Why it matters
    This large-scale retrospective study—authors believe it's the first to analyze how state limits on PT access affect utilization and costs—adds to the evidence that direct access to a PT for LBP (and seeing a PT first) achieves effective results. The cost differences alone are potentially significant, given the estimate that as many as 70% of people will experience LBP in their lifetimes, making it "the third most costly medical condition in the United States," according to authors.

    More from the study
    Authors were particularly interested in the findings that patients in provisional-access states who saw a PT first tended to incur higher cost and utilization than those whose index visit was with a PCP. Authors believe the explanation for the difference may have something to do with the way the restrictions tend to increase the need to visit physicians following the initial PT visit to comply with requirements around, for example, imaging or specific procedures.

    Similarly, authors theorize that the cost ratio—in other words, the magnitude of the differences—may also be due to the pressures provisional-access systems bring to bear on LBP treatment.

    "Given that patients in provisional-access states often are required to see a PCP after a certain number of physical therapist visits or required a PCP shortly after the initial physical therapist visit, these additional visits likely increase the cost of care in provisional-access states," authors write. "Since physician gatekeeping does not occur in unrestricted-access states, which would increase the cost of care, we would postulate that this restriction accounts for the differences in 30-day costs between provisional-access states and unrestricted-access states."

    APTA's role
    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP as well as the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and the investigation included in this review. APTA cosponsored all 3 studies

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients and were limited to evaluation of only "certain variables." Additionally, data from patients in states that changed their access regulations between 2008 and 2016 were excluded, reducing sample size.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    [Editor's note: McDonough is the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant and of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    Technology's Brave New World of Ethical Challenges Explored in PT in Motion Magazine

    That latest piece of technology you're thinking about weaving into your practice? Maybe it should come with a warning label.

    This month, PT in Motion magazine takes a look at the ethical issues that new technologies can introduce in physical therapist practice. From seemingly offhand social media posts to the use of voice assistant devices (VADs) such as Alexa to mounting cameras in clinics, experts interviewed for the story explain the ethical considerations that need to be weighed before powering up.

    "New Technology: Keeping It Ethical, Keeping It Legal" focuses on 7 general areas of technology: providing online advice, posting photos, VADs, wearable technology, use of cameras, electronic health records, and telehealth. PTs interviewed for the article include APTA Ethics and Judicial Committee Chair Bruce Greenfield, PT PhD, FAPTA; APTA Section of Health Policy and Administration member Robert Latz, PT, DPT, who's also the section's representative on the association's Frontiers in Rehabilitation, Science, and Technology Council; and Nancy Kirsch, PT, DPT, PhD, FAPTA, president of the Federation of State Boards of Physical Therapy and author of PT in Motion's "Ethics in Practice" column.

    As it turns out, although the technologies themselves may be new, the potential ethical pitfalls may sound familiar: issues that can be associated with new technology—such as jurisdictional permission to practice, patient privacy, records confidentiality, and honest patient communications—didn't arrive with the first computer. Longtime ethical standards still apply: the danger lies in the ways rapidly advancing technology can overshadow those standards, potentially harming patients—and ruining careers.

    "New Technology: Keeping It Ethical, Keeping It Legal" is featured in the November issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also among the content available to all viewers: "Serving Veterans Through Community Programs," a primer on care options available to military veterans.