The Heart of the Storm: I'm a PT in Manhattan. Here's What it's Been Like
By Katie Parrotte, PT, DPT
It seemed to happen nearly overnight. One day my schedule was full and our clinic was bustling, and the next the cancellations came sweeping in. I wrapped up one work week knowing I was receiving a salary, and came in the next to be told my company could no longer pay me my salary, but would give me a set stipend per patient visit I completed. The next week, I was filing for unemployment — something I never imagined I would ever have to do as a health care provider.
I work in Manhattan, which is currently the U.S. epicenter of the COVID-19 pandemic, for a small outpatient orthopedic company. We serve nearby residents of all ages: from school-aged children to elderly patients brought in by home health aides; from the weekend warrior to newly postpartum mothers. With 14 physical therapists working over a span of 13 hours, five days a week, the clinic was humming with activity. However, in a matter of a few weeks this dramatically changed.
As the threat of COVID-19 became more imminent, the owners and clinic directors began taking steps to protect the staff and our patients. Signs were posted educating patients on Centers for Disease Control and Prevention recommendations to prevent the spread of disease, and all patients were required to wash their hands upon entering and prior to leaving the clinic. Each therapist was supplied with nitrile gloves and a container of germicidal disposable wipes for their treatment station, to clean the tables between patients (in addition to the usual changing of linens between patients). A member of our front desk staff began regularly wiping down frequently touched surfaces and door handles throughout the clinic. While the clinic is fortunate to have these supplies, it is unclear how easy it would be to purchase more in the near future.
When the rate of infection began to increase in New York City about two weeks ago, we still did not have masks at our clinic; one of the owners was able to obtain 10 surgical masks, but was having trouble finding more. This is par for the course, as many health care providers, including those “in the trenches” in hospital settings, are unable to get enough of the supplies they need. I have friends in hospital outpatient settings who are facing the same shortages. One friend was told to make a surgical mask last for three days, so she keeps it in a Ziploc bag between her treatment sessions. Another friend has been given one surgical mask for the foreseeable future. If New York City hospitals and hospital-based physical therapy clinics are facing such shortages, it comes as no surprise that private outpatient facilities will also experience shortages, perhaps to an even greater degree.
Aside from limited supplies, the ever-worsening situation in NYC is greatly affecting the financial stability of the clinic. At first, cancellations began to trickle in slowly, starting with older or at-risk populations. However, since the clinic serves as a community clinic, many of our patients are over the age of 65, so the number of cancellations continued to increase. As more businesses closed and New York State put mandates in place restricting the workforce, more patients began cancelling appointments. After the state mandated that 100% of nonessential personnel stay home initially for two weeks, and now until April 15, many patients have canceled their appointments until at least May.
For patients who continue to come into the clinic, the task of pre-screening is a challenge. As a small business, the company does not have technology such as digital temperature readers, nor does the clinic have an isolated area where patients can be screened prior to having contact with other people. To help minimize the sick or exposed patients coming to the clinic, the company lifted all fees for late cancellation of appointments, and therapists relied on patients reporting travel, exposure, or being ill to determine whether an individual should be treated at the clinic.
Nobody was prepared for this, but it feels like a nearly impossible situation for small private practices. Owners and employees alike are forced to make challenging decisions: Stay open and risk exposure? Close your doors and risk never opening them again? If patients are willing, should therapists continue treatment despite increased risk and decreased pay? Can they afford not to? This is all compounded by the constantly changing circumstances and guidelines that we are all struggling to adapt to on –the fly.
Hopefully this pandemic will be on the downswing within the coming weeks, and other areas will not be hit as hard as New York City and New York State have been. However, for those of you in other areas of the country, now is the time for you to start planning and making changes in your practices to help minimize the impact this has on your patients and your businesses, if you haven’t already.
If your clinic is still open, try to get as many supplies as you can, including gloves, surgical masks, and germicidal wipes. If you have not already done so, begin practices of surface disinfecting (including chairs, door handles, and counters) between each patient to help minimize the spread of disease. Cut out as much nonessential spending (both personal and professional) as possible in an effort to save money, for these are uncertain times, and we do not know how long this pandemic will last, how long individual business will be able to remain open or individual employees will be paid. If you have not already, start going through your patient lists and prioritize patients. Is there anyone on your caseload who is truly essential – whose life would be worse off without having physical therapist services during this time, such as patients who recently had surgery or have acute neurologic complaints? On the opposite side of the coin, are there patients who are in the high-risk category for COVID-19 morbidity and mortality who should stay home? If there are patients who absolutely require in-person physical therapist services during this time, take the appropriate steps to ensure that these individuals are otherwise healthy, and use PPE as it is available. However, if it is not critical that a patient receives in-person services, consider transitioning that patient to virtual care.
In light of the current situation in NYC, I believe that engaging our patients via telehealth is the best and the safest way to continue providing care. We as health care providers have a responsibility to continue treating our patients, but to also minimize the risk of exposure for our patients, especially the most vulnerable ones, and for ourselves. With morbidity and mortality numbers continuing to climb in NYC, we must put the safety of the public as a whole over our fear of losing money.
While rules and coverage for telehealth vary by payer and by state, many payers are becoming more lenient in light of the current crisis the country is facing. There are many great resources available on telehealth, including on the APTA website and on many APTA chapter websites. The New York Physical Therapy Association Executive Committee and chapter staff have been working tirelessly to provide PTs and PTAs in our state with the best available information to help us all continue to practice and to advocate for our profession.
This is a challenging time for us all: Our patients are not getting the type of care we are used to providing, clinics are losing money, PTs and PTAs are losing jobs, and more people across the nation continue to get sick. I think the best we can do is be flexible and think outside the box when finding ways we can provide care for our patients. Overall, we should remember that we are #BetterTogether, and we work together to provide the best care, whether it is in person or virtually. If we can do this, I believe that when we get on the other side of this crisis, we will find ourselves stronger and more dynamic, both as individuals and as a profession.
Katie Parrotte, a board-certified orthopaedic clinical specialist, is director of pelvic health and H&D Physical Therapy. She is a director for the Greater New York District on the Board of Directors for the New York Physical Therapy Association.
Thinking About Providing Telehealth? Here's Our Top 10 'To-Do' List
The COVID-19 pandemic has caused patients and providers, as well as state and federal governments, to consider the use of telehealth on a wider scale, including in physical therapy.
It's a complicated topic that deserves your time — not just because of the immediate need for change to help respond to the current health crisis, but because the expansion of telehealth to physical therapy has been long sought by many in the profession, and it is one of APTA's central advocacy targets.
APTA offers extensive resources on telehealth on its telehealth webpage, and we're adding information frequently as the on-the-ground realities continue to develop. You should review those resources before making a decision about whether telehealth is the right approach for you — or if it's even possible.
Arm yourself with as much information as possible—and follow these 10 telehealth "to-dos."
1. Know what's allowed and what's not.
Regardless of the payer or policy, if you provide and bill for telehealth services, you must do it legally and ethically. That means adhering to state and federal guidelines and paying particular attention to the laws and regulations in your state of licensure.
Understand that not all states allow telehealth by PTs or PTAs and that even among those that do, there are variations in what exactly is permitted. It doesn't matter what a commercial payer may allow, or even what CMS permits: If your state says telehealth is outside your scope of practice, you can't use it to provide services.
Carefully review your state licensure law and regulations, but remember that in many states, the law is silent on telehealth and physical therapy. If that's the case in your state, contact your state's licensing board to find out if there are limitations or restrictions. For more information, check out APTA's state practice act resources, and information from the Federation of State Board of Physical Therapy. And remember that state-mandated health orders and state emergency orders can also change what is and isn't permitted.
2. Train your staff.
Solid staff training is key to an effective telehealth program that best responds to the COVID-19 pandemic. APTA offers several resources to help you ensure that your staff is as prepared as possible for providing telehealth in this crisis. Check out these two APTA Learning Center webinars: Implementing Telehealth in Your Practice , recorded on March 26, and Digital Telehealth Practice – Connect for Best Practice, Healthcare, and Compliance, to be recorded on April 2, with a live online Q&A on April 7.
3. Educate your patients on their privacy and rights.
You need to properly educate patients about the use of telehealth, which includes their rights while being cared for under this modality. Patients need to be aware of your obligation to protect their privacy and gain their consent. For more information about informed consent, check out the Center for Connected Health Policy resources.
4. Take privacy seriously — and understand how it's affected by technology.
You need to understand the technology of telehealth, and the extensive regulation in place to protect patient privacy and security of health information, including HIPAA requirements. Also check out the additional resources listed at the end of this blog.
5. Document, document, document (just like always).
Keep in mind the documentation needed to have a proper compliant telehealth program. For more information, view APTA's Defensible Documentation resources.
6. When it comes to payment, assume nothing.
Your practice can involve multiple payers, with differing policies, including those related to telehealth. This means you'll face a patchwork of approaches.
You should command a sound understanding of variations in telehealth reimbursement, be it through Medicare, Medicaid, other federal health payers, or commercial payers. Verify with individual payers what is and isn't permitted, what CPT codes will be reimbursed, the required modifiers, and more. Confirm with each payer whether the originating and distant site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. This APTA article offers guidance on what questions to ask your payer(s).
Also find out if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit. For more information, check out APTA's Telehealth billing and coding resources.
7. Make sure your malpractice insurance covers telehealth.
You should check your malpractice insurance and update it if it doesn’t cover practice using telehealth. For more information, see APTA's Risk Management resources as well as the resources listed at the end of this blog.
8. Understand that your ethical responsibilities don't change when delivering services via telehealth.
It's simple: You are held to the ethical standards of your profession while practicing telehealth. Here are some resources you should review regarding ethics in telehealth. Also, check out a free APTA Learning Center webinar that discusses what you need to know to ensure compliance with regulations established by HIPAA and the APTA Code of Ethics when using telehealth and mobile health technology. Also worth a look: this blog post highlighting ethics, best practice, and law considerations for practicing telehealth.
9. Stay connected with your peers in telehealth.
Telehealth is part of APTA's Frontiers in Rehabilitation, Science, and Technology (FiRST) Council. FiRST grew out of identification of high-priority areas to advance science and innovation that our profession needs to understand and incorporate into our practice, education, and research. FiRST is intended to serve as a community for interested stakeholders, and is a great way to learn from those who've been leading the way.
10. Advocate.
Remember that most of the opportunities for telehealth at the moment are temporary, in response to the COVID-19 pandemic. And as of this writing, even though CMS now has the (again, temporary) authority to include PTs among the providers who can engage in telehealth, it hasn't moved in that direction. That’s why it's so important to continually advocate for payment and coverage policies that ensure patients have access to the rehabilitative care they need. Learn more about how you can engage in federal advocacy today and watch for advocacy opportunities on the state level.
More Telehealth Resources for PTs and PTAs
HIPAA: Business associate agreements
FERPA
COPPA
Health IT and telehealth
HPSO: Telemedicine: Risk Management Issues, Strategies, and Resources
APTA: Considerations for Practice Opportunities and Professional Development
HHS Security Risk Assessment Tool
HPA Tech SIG: SIG's homepage.
Novel Coronavirus: A Wake-up Call for Best Practices in Preventing Pathogen Transmission
By David Levine, PT, DPT, PhD, FAPTA, Henry Spratt, PhD, June Hanks, PT, DPT, PhD, and Charles Woods, MD, MS
Novel human coronavirus disease (COVID-19), now moving towards pandemic status, represents one of the great concerns of modern life – the rapid evolution of new human viruses that can be spread via the respiratory tract. As with other pathogens, physical therapists, physical therapist assistants, and administrative staff can take tangible steps to help prevent the spread of disease that could harm our most vulnerable populations. The Centers for Medicare and Medicaid Services has issued guidelines for infection control and is calling on health care providers to activate infection control practices.
COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, abbreviated as SARS-CoV-2. As a positive-strand, enveloped RNA virus, SARS-CoV-2 is another coronavirus like the severe acute respiratory syndrome (SARS) virus that first appeared in China in 2002, infecting around 8,000 people worldwide and resulting in about 750 deaths in total. The major lesson learned from the SARS outbreak was how easily these coronaviruses can spread. To avoid additional spread of these viruses requires effective detection, protection of caregivers (eg. hand washing, protective clothing, and masks for infected individuals), and disinfection of health care facilities and equipment. These measures are a must for all physical therapy clinics.
There is still much to learn about the new virus, including how easily it spreads. Based on what we currently know about other coronaviruses, SARS-CoV-2 is spread mainly from person to person through respiratory droplets among close contacts, especially under crowded conditions. It is easy to see how the first cases of COVID-19 appeared in Wuhan, China, a large city about the size of Chicago last December. However, this new virus is not the only airborne virus that can cause epidemics — think influenza.
In addition to taking precautions to avoid aerosolization (the production of airborne particles containing an infectious virus or bacteria), we must disinfect surfaces touched by infected people. Thus, in physical therapy clinics, in anticipation of future patients being infected by the SARS-CoV-2 virus, we must think holistically in terms of clinic disinfection and protection.
What Should We Be Doing in Physical Therapy to Prevent Pathogen Transmission?
Most people infected by the virus — around 80% — show mild symptoms, much like having the common cold, from which they will recover over the course of several weeks. It is the remaining 20% of people who are most at risk of more severe symptoms and potential critical outcomes. This latter group includes older individuals, the very young, and immunocompromised patients. Keeping individuals with mild symptoms away from the most susceptible persons is paramount in reducing serious complications and even death.
By the nature of our profession, physical therapists and physical therapist assistants use our hands and therapeutic equipment extensively and have frequent direct patient contact. We also work in crowded environments and with individuals that may be immunocompromised. While there are many precautions we can take that are specific to SARS-CoV-2, the virus serves as a reminder for all health care providers and administrators to be vigilant in preventing the spread of any transmissible disease or infectious bacteria.
1. Practice proper hand and wrist hygiene.
When you don't know what you don't know, then do what you do know: Wash your hands—and your wrists! Hand and wrist hygiene should occur before and after each patient encounter.
With the very short time between this writing and actual publication, researchers will learn more about COVID-19 and recommendations are likely to expand. That said, the practice of appropriate handwashing remains as the most basic strategy to prevent the spread of SARS-CoV-2, the influenza virus, and the common cold. Proper hand/wrist hygiene using soap and water or alcohol-based hand sanitizers (ABHS) significantly impacts microbe transmission and should be incorporated into routine patient care.
Handwashing with soap and water is recommended after treating patients with known or suspected norovirus or Clostridium difficile, since ABHS are not effective against these pathogens, and is recommended for SARS-CoV-2 as well. While soap doesn't kill the virus, it does wash it away if done properly: Wash hands with soap and water, place the hands under running water, apply the soap, and vigorously rub all surfaces of the hands and wrists together for 15-20 seconds (sing "Happy Birthday" twice), rinse, use a disposable towel to dry, and use the towel to turn off the water faucet. Make sure you clean under your fingernails, as well.
ABHS are the most efficacious method to reduce bacteria on the hands and wrists. ABHS should be used according to manufacturer recommendations, which generally include putting the product on and rubbing all surfaces together for at least 20 seconds until dry. If it is dry before 20 seconds, you have not used enough ABHS.
Fingernails should be kept less than ¼ inch long, and excessive jewelry should be avoided. Frequent use of hand lotions that do not interfere with hand sanitizing products may help reduce hand dryness from frequent cleansing.
2. Cover your coughs and sneezes with a tissue.
Cover your mouth and nose with a tissue when coughing or sneezing. If no tissue is available, sneezing or coughing into a bent elbow is recommended. It may prevent those around you from getting sick. Flu and other serious respiratory illnesses, like respiratory syncytial virus (RSV), whooping cough and SARS, are spread by cough, sneezing, or unclean hands.
3. Stay home when you are sick.
If possible, stay home from work, school, and running errands when you are sick. This will help prevent spreading your illness to others.
4. Avoid touching your eyes, nose, or mouth.
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Cleaning and Disinfection in the Clinic and Other Settings
This is an area that we don't emphasize enough within the physical therapy profession. No matter what type of practice setting, we all have objects and equipment — tables, walkers, wheelchairs, goniometers, pulse oximeters, crutches, gait belts, exercise equipment, countertops, treadmills, light switches, doorknobs, cabinet handles, etc. — that are frequently touched and contaminated. We don't yet know how easily SARS-CoV-2 can be transmitted by objects, but as a rule surfaces should be cleaned between each patient encounter using an appropriate disinfectant. The Environmental Protection Agency has released a list of disinfectants approved for use against the SARS-CoV-2 virus.
It is beyond the purpose of this blog to discuss the numerous types of disinfectants that have advantages and disadvantages in terms of effectiveness, kill time, safety, cost, and ease of use. For example, hydrogen peroxide wipes are commonly used in health care, but take one minute of contact/wet time to kill methicillin resistant staphylococcus aureus (MRSA), three minutes of contact/wet time to kill norovirus, and five minutes to kill mycobacterium bovis. How often do we achieve a wet time of even 30 seconds when cleaning equipment? The bottom line: Read the labels and learn about the products.
For more information on where bacteria commonly grow in the clinic and how to prevent its spread, see this blog post.
PTs who work in home health don't have as much control over their environment, but should still practice hand and wrist hygiene, "distancing" (avoiding droplets from a patient's cough) as much as possible, and avoiding patient visits when they are ill.
What If My Patient Is the One Coughing/Sneezing, or Exhibits COVID-19 Symptoms?
Advise patients who are sick to call their primary care providers and stay at home. It is hard to know how to tell people when and when not to go see their doctor, urgent care center, or minute clinic. The Centers for Disease Control and Prevention currently recommends that you call your physician if you develop a fever, cough, and shortness of breath AND have been in close contact with a person diagnosed with COVID-19 or have recently traveled from an area with ongoing spread of SARS-CoV-2.
Request patients who are coughing or sneezing to wear a mask while in the clinic and, if possible, move them into an individual room for treatment. Provide alcohol-based hand sanitizer and face masks at all facility entrances. Educate your patients on proper hand and wrist hygiene and the other preventive practices outlined above.
Make a plan for how you will educate your front desk and clinical staff about protecting themselves and cleaning their workspace frequently.
The World Health Organization website includes the following helpful resources:
David Levine is professor in the department of physical therapy at The University of Tennessee at Chattanooga (UTC) and a board-certified clinical specialist in orthopaedic physical therapy. June Hanks is associate professor in the department of physical therapy at UTC. Henry Spratt is a microbiology professor in the UTC department of biology, geology, and environmental science. Charles Woods is chair of the department of pediatrics of the UT College of Medicine Chattanooga and professor of pediatric infectious diseases.
This Is APTA: Senora Simpson, PT, DrPH
Senora Simpson, a clinician and educator, has been inspiring PTs for over half a century — first through her bravery as a PT struggling to pursue her career during segregation, and later as an influential educator, policy maker, and advocate for people with mental health and intellectual disabilities. She also was recognized with the Lucy Blair Service Award in 2008. Here is her story.
Senora Simpson, PT, DrPH, has been an active APTA member since 1957, and has lived in Washington, D.C., most of her life. A proud 1953 graduate of D.C.'s academically elite Paul Laurence Dunbar High School, Simpson originally wanted to be a pianist, until her mother persuaded her to pursue a more lucrative career in physical therapy.
At Boston University's then all-female Sargent College of Allied Health Professions (now Sargent College of Health and Rehabilitation Sciences, Boston University), Simpson earned her bachelor's degree in physical therapy. She was one of two African American students in her class. Her professors included the late Margaret L. Moore, PT, EdD, and Helen K. Hickey, PT, MEd, who became mentors along the way.
According to Simpson, Moore and Hickey, who later served as members of the APTA Board of Directors, were "very protective" of her, because, as an African American woman, her "chances of success were slim." In fact, Hickey would not allow her to complete an affiliation at DC Children's Hospital because she feared that Simpson would be failed due to racial bigotry. Instead, she sent Simpson to Cooley Dickinson Hospital in Northampton, Massachusetts — a fortuitous move, because there she learned the groundbreaking technique of spine and joint manipulation and became quite skilled at manual muscle testing while treating patients with polio.
"I Cured Polio!"
It also was Hickey who called on Simpson soon after graduation to fill a position in Brownsville, Texas, where there was a breakout of polio. Hickey had become affiliated with The National Foundation for Infantile Paralysis (now known as the March of Dimes) and learned that physicians there were in need of PTs with superior manual muscle testing skills. It seemed like a natural fit, until the Texas hospital administrators learned that Simpson was African American. In a time when segregation was still in legal effect, the hospital gave up her valuable skills. In her 2003 APTA oral history, Simpson joked that when she heard the hospital "didn't need anybody" after all, she thought to herself, "I cured polio!"
From Hands-on Clinician to Testing New Models of Care
After a stint at Goldwater Memorial Hospital in New York City, part of the Rusk Institute of Physical Medicine, in 1959 Simpson moved back to D.C. to take a position as staff PT at D.C. General Hospital, beginning a more than 30-year career in government service. After nearly a decade at D.C. General, Simpson made the move from clinician to administrator, going on to develop the rehabilitation department at St. Elizabeth's Hospital, which served patients with mental illness.
In 1965, the U.S. Department of Health, Education, and Welfare — precursor to the Department of Health and Human Services — began the Comprehensive Home Care Project, a demonstration project to see whether rehabilitation could be performed for older adults in their homes, which was a novel idea at the time. Until then, home health rehab outside the hospital setting was not an option. Simpson took on the role of overseeing this effort for the D.C. region, coordinating PTs, occupational therapists, and speech-language pathologists.
Policy and administration appealed to Simpson, leading her to earn a doctorate in public health from University of Southern California in 1978. "I think about physical therapy differently [from how a clinician does]," she says, "because I think about the broader picture, about health care provision in a community, in a state."
"I Have To Be Part of the Solution"
Simpson began to pursue her master's in public health at The Johns Hopkins University while working at Forest Haven, an institution for people with intellectual disabilities. Her experience there as the first nonphysician head of health services inspired her involvement in the movement for deinstitutionalization for people with intellectual disabilities.
Her ongoing interaction with regulators and legislators led her to get involved in developing the health policies that affected patients, first writing HHS regulations for early and periodic screening, diagnostic, and treatment and later working as director of regional operations at the Office of Human Development Services, which oversaw Head Start, children and youth services, and the Office on Aging.
After watching her grandson struggle with dyslexia, Simpson became an advocate for special education and continues to be active in community advocacy organizations. She also has served in leadership roles with District of Columbia ARC and the National Capital Area United Way.
Many Hats
Although she retired from the federal government and her 25-year evening private practice many years ago, Simpson is assistant professor at Howard University and previously taught at George Washington University. "Students and their interest in learning are keeping me alive!" she declares. "They are teaching me things. But I'm tough. I don't do extra credit. I don't do anything that won't result in a good clinician."
She also spent 15 years on the D.C. Board of Physical Therapy, including as chair. Throughout her career, Simpson has remained involved with the D.C. Chapter of APTA, at various times holding the offices of president, membership committee chair, secretary, and delegate. The chapter even named an annual award for her: the Senora Simpson Service Award.
Currently Simpson serves on the board of directors of Qlarant, a company that performs quality review for the Centers for Medicare and Medicaid Services, and chairs Qlarant's Quality Solutions Committee.
#PTTransforms blog spoke with Senora Simpson to get her thoughts on the state of the profession, where we've been, and where we need to go.
#PTTransforms: You had some good mentors early in your career. What advice do you have for future or new PTs and PTAs seeking mentorship?
Simpson: Be true to yourself. Be sure about why you are going into this profession. If you don't want to do it for the long-term, get out now. You've got to want to do this work with all your heart and soul. I see some people going into the profession for the title or the money, and no true passion for helping people. You aren't going to get a mentor unless you are truly interested.
Some students may say, "I want you as a mentor," but really they just want to use my name. Helen Hickey called me because she remembered my skills in school. They needed someone who was skilled in manual muscle testing to help physicians. It wasn't because I asked her to be my mentor. She knew what they needed, and she knew what I could do.
#PTTransforms: You have said that "there is still a lot of work to do" with regard to diversity in the profession. What do you think the profession needs to do?
Simpson: There is no group of people who should be treated differently [from the population as a whole]. You don’t need to separate out groups and learn how to treat them. You shouldn't have to have special training. You need to learn how to be a human being. You've just got to be a good person to begin with. You can't legislate morality. You either have boundaries and morals that were taught to you, or you don't. You can take every class in the world, but if you really don't believe in it you are going to keep doing [the wrong thing].
APTA has tried to increase minority participation. We can have all kinds of goals, but it's at the ground level that it counts.
#PTTransforms: So what should the profession do in this area?
Simpson: There is hope in the world. There has to be societal change first, and then it will come into our profession. It is amazing to me what the #MeToo movement was able to do in a short period of time. We need a #MeToo movement in health care with regard to inclusion. We need to study what #MeToo did to move society. It's the only thing that will change the complexion of APTA.
[For some], the bottom line is image; sincerity is what we need.
#PTTransforms: In your oral history, you said that if you talk about a problem, you feel you have to be part of the solution. There are some strong voices in the debates over issues such as health care reform, school loan debt, and payment for services. What do you have to say to PTs, PTAs, and students who want to speak up but feel drowned out by those voices?
Simpson: Most of the things [the profession has] achieved started out with one voice. If you are a reasonable person, people will listen to you. Be careful to do your research in order to support your position with facts — not because your grandmother said so. Know what the rules are, know what is being proposed, in depth, to decide [how you will make your case]. And listen to other viewpoints.
If we can get one person who speaks truth to power, that's all we need. But you have to believe it when you speak it.
Part of the reason I joined APTA was to raise hell [about Medicare]. It was so much fun. I recently went down to [Capitol Hill to] testify in favor of the Physical Therapy Compact! That [willingness to speak up] is what I want to see in all health care providers. Get out of smoothing salve on people, and improve the health of America [through advocacy].
Busting Medicare Myths (and Regulating Your Expectations), Episode 3
PDPM, Maintenance Therapy, and the Medicare Outpatient Therapy Threshold
By Kara Gainer, JD
The U.S. Centers for Medicare and Medicaid Services isn't known for easy-to-understand rules and regulations around Medicare. Unfortunately, that complexity can lead to misinformation, which can spread quickly.
In an effort to get everyone on the same page, I'm debunking some of the most prevalent Medicare myths I've been seeing lately on social media and in other venues. (Have a question that you would like addressed in a future installment? Send your ideas to advocacy@apta.org with "mythbusting" in the subject line.)
Myth: CMS changed the coverage requirements of OT, PT, and SLP services furnished in a skilled nursing facility.
Although the payment methodology for SNFs changed in October of last year, the criteria for skilled therapy coverage didn't: Patients must receive the skilled therapy services they need. Skilled therapy services are now reimbursed by Medicare under the Patient-Driven Payment Model, or PDPM. While PDPM does change the manner in which patients are classified into payment groups under the SNF prospective payment system, it does not change any of the coverage criteria or documentation requirements associated with skilled therapy service coverage. But most important, PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies made on their behalf.
Resources:
CMS Fact Sheet on PDPM
APTA handout: What You Should Know About the Patient-Driven Payment Model
Myth: SNFs should require therapists and assistants to deliver the maximum amount of concurrent and group therapy (25%) for each discipline for each patient.
Although the PDPM includes a combined limit on group and concurrent therapy of 25%, you should deliver the mode(s) of therapy best attuned to individual patient needs and goals, and incorporate the provision of group and concurrent therapy into the patient’s plan of care. Group therapy documentation requirements remain the same: You must plan for a group in advance and document how group therapy will help each patient achieve their goals.
Resources:
CMS Fact Sheet on PDPM (see "Concurrent and Group Therapy Limit")
APTA webpage: SNF Patient-Driven Payment Model
APTA handout: group vs. individual care decision tree
Myth: Medicare does not cover skilled maintenance therapy.
This one has persisted for a few years. There has been a longstanding myth that Medicare does not cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible. But it's just not true, and the Jimmo v. Sebelius final settlement sought to dispel this fallacy and clarify the rules to safeguard against unfair denials by Medicare contractors. The settlement agreement and the resulting revised manual provisions clarify that the Medicare program covers skilled therapy and skilled nursing services under the SNF, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline or deterioration (as long as all other coverage criteria are met). Specifically, the Jimmo settlement agreement required revisions in various CMS manuals to clearly state a "maintenance coverage standard" for both skilled nursing and therapy services. Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program.
Resources:
APTA webpage: Skilled Maintenance
CMS webpage: Jimmo Settlement
Myth: Maintenance therapy is not supported by PDGM.
Here's how CMS puts it in 2020 home health final rule: "It is the responsibility of the patient’s treating physician to determine if and what type of therapy (that is, maintenance or otherwise) the patient needs regardless of clinical grouping. CMS expects the ordering physician, in conjunction with the therapist, to develop and follow a plan of care for any home health patient, regardless of clinical group, as outlined in the skilled service requirements when therapy is deemed reasonable and necessary. Therefore, a home health period’s clinical group should not solely determine the type and extent of therapy needed for a particular patient." Also, beginning this year, PTAs can perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements.
Resources:
CMS 2020 home health final rule
APTA handout: What You Should Know About the Patient-Driven Groupings Model for Home Health Services
CMS MLN Matters: Manual Updates Related to 2020 Home Health Payment Policy Changes
Myth: You must discharge patients from physical therapy when they reach the Medicare payment outpatient therapy threshold or targeted medical review threshold.
As long as skilled physical therapy continues to be medically necessary, you shouldn’t discharge Medicare patients when they reach the outpatient therapy threshold or the targeted medical review threshold. What used to be the Medicare therapy caps now are annual thresholds that you can exceed when you append claims with the KX modifier for medically necessary services. This change from the earlier "hard" therapy caps is the result of the Bipartisan Budget Act of 2018 (BBA of 2018), which provides for Medicare payment for outpatient therapy services including physical therapy, speech-language pathology, and occupational therapy services. If services exceed the annual threshold amounts, nclude the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. If you furnish medically necessary services over the targeted medical review threshold of $3,000, continue to affix the KX modifier and maintain the documentation to justify it. This medical review focuses on categories of providers deemed a higher risk for rejected claims.
Remember that the threshold is for physical therapy and speech-language services combined. I'll cover why that's the case in the next installment of this series.
Resources:
APTA mythbusting blog series, episode 1
APTA webpage: Medicare Payment Thresholds for Outpatient Therapy Services
CMS Q&A sheet: Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage
CMS webpage: Therapy Services
Kara Gainer is APTA's director of regulatory affairs.
The PTA Differential: How We Got Here, and What's Next
By David Harris, PTA, MBA
If you've spent much time following APTA's social media feeds or reading comments on the association's news or blog posts, you know that the payment differential for services provided by physical therapist assistants (PTA) set for 2022 is sparking a significant amount of concern and frustration in the physical therapy community.
And with good reason: Nobody wants to see payment decrease for such a crucial profession. On top of that, the coding system CMS was compelled by the legislation to implement to document when services are delivered "in whole or in part" by a PTA or occupational therapy assistant, while improved over its original plan, still has flaws.
But for some, there's another element to the frustration they're feeling: They’re wondering how we got here and what APTA is doing about it. And that's understandable, too, because legislation and regulatory rulemaking are complicated and sometimes messy, and it can be a challenge to keep up even if you’re working hard to pay attention.
So let's walk through it.
Where It All Started: One Enormous Piece of Legislation
The PTA modifier and payment differential weren’t changes dreamed up by CMS — Congress put this policy in the legislation that became the Bipartisan Budget Act, or BBA, of 2018.
You may remember this law when it was passed, because it was huge. It included, among other provisions, $90 billion for hurricane relief efforts, two years of funding for community health centers, $6 billion over two years to address the opioid crisis, a four-year extension of the Children’s Health Insurance Program, a suspension of the debt ceiling, and much more.
The BBA also required that by January 1, 2019, CMS establish a modifier to indicate when an outpatient physical therapist service is furnished in whole or in part by a PTA. The use of the modifier was mandated as of January 1, 2020, for outpatient therapy providers across almost all settings — including private practices, skilled nursing facilities, home health agencies, outpatient hospitals, rehabilitation agencies, and comprehensive outpatient rehabilitation facilities. Starting January 1, 2022, outpatient physical therapy services covered under the Medicare physician fee schedule that are furnished at least in part by a PTA — as identified by the modifier — will be paid at 85% of the applicable fee schedule rate. A similar modifier was designated for services provided by an occupational therapy assistant, which also will be subject to the 85% payment differential.
A Last-Minute Addition With no Chance for Discussion
So how exactly did this mandate to CMS get included in the BBA? Basically, it was included in the legislation at an 11th-hour by members of the U.S. House of Representatives. This policy had not been part of any of the discussions or negotiations during the previous year regarding the therapy cap, nor was it included in any proposed fixes, such as the Medicare Extenders package announced in October 2017. On the evening of Monday, February 5, 2018, with no warning to APTA, the PTA differential policy appeared in the House budget proposal.
As soon as the proposal was released, APTA leaped into action, along with the American Occupational Therapy Association. Both associations objected to the change and gave alternative legislative language to members of the U.S. Senate on Tuesday, February 6, and Wednesday, February 7. The Senate’s response? They told us there was no opportunity to alter the policy. Both the House and Senate packages were “baked” prior to release. The BBA was signed into law on Friday, February 9.
Therapy Cap Tradeoff? Nope
There's a notion floating around that the PTA differential was adopted to "pay for" the therapy cap fix. Not true. The PTA policy was just one of many policies adopted by Congress to pay for its legislative initiatives within the BBA legislation. Rather than allow for timely discussion about its merits among stakeholders, Congress waited until the very last minute to insert the change and then refused to listen to the therapy associations’ suggested improvements or refinements to the legislative language. Just because the therapy cap fix was a positive development of the BBA doesn’t mean that Congress traded one thing for the other. And with $38 billion in adjustments to the current operating models of the health care programs, the physical therapy profession was going to be touched somehow.
From Legislation to Rulemaking
With the legislation now signed into law, CMS was required to adopt a modifier in order to identify when a service is furnished in whole or in part by a PTA or OTA. It also had to interpret what Congress meant by "services furnished in whole or in part" — no small task. Recognizing the ball was now in CMS’ court, APTA directed its advocacy to CMS to ensure that the agency interpreted the policy to, as much as possible, have minimal impact on patients and providers.
The journey toward the system now in place was a bumpy ride. In the 2019 physician fee schedule proposed rule (released in July 2018), CMS proposed a definition of “in whole or in part” as a service for which any minute of a therapeutic service is furnished by the assistant. Needless to say this was completely unacceptable, as well as unworkable from a practical standpoint. APTA fought back.
Responding to feedback from APTA and other stakeholders, CMS revised its proposed definition in the 2019 physician fee schedule final rule and defined a standard for "in whole or in part" as more than 10% of the service being furnished by the PTA or OTA—an approach known as use of a "de minimis" standard. While the finalized definition was less than ideal, it was an improvement upon the “any minute” proposal. And it occurred because we met with CMS and submitted detailed comments against the “any minute” proposal — otherwise it would've been full steam ahead on a terrible plan.
In the 2020 physician fee schedule proposed rule (released in July 2019), CMS proposed how this de minimis 10% standard would be applied. When CMS proposed how the modifiers would be used—"CQ" for PTAs and "CO" for OTAs —it forwarded a 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, in addition to meeting with the CMS Administrator and agency staff.
A Better — But Far From Perfect — Final Rule
Because of the collective efforts of APTA members and staff, CMS took notice and clarified how the new standard would be applied. While it hung on to the policy that the modifier must be applied when 10% or more of the service is delivered by a PTA or OTA, the agency’s final rule for 2020 backed away from many of the more problematic elements of its proposed plan.
And that's where we are now.
About All That Letter-Writing…
Our efforts to shape the final version of the application of the CQ modifier involved extensive communication with CMS, including meetings with the agency and submitting comment letters, both from the association itself and thousands of individual members and other stakeholders. You may think that letter-writing isn't an especially effective way of doing advocacy. That's just not so.
Submitting written comments to CMS (or any federal agency) on a proposed rule is an important way to have your voice heard on regulations that can have a large impact on your and other people's lives. Public comments provide regulators with information to help them improve their rules and may even lead to changes in regulations. This is why APTA is so passionate about having the profession use its voice to advocate to CMS and other federal agencies when there are opportunities for comment — it's one of our most crucial, most direct connections with the people actually crafting the rules we'll have to live by.
What's Next
There's no denying that the PTA payment differential set to go into effect in 2022 is disappointing. But in figuring out the pathway forward it's essential to recognize that the physical therapy profession isn't being singled out: Other essential health care providers, such as physician assistants, clinical social workers, and nurse practitioners, are paid at 85% of the fee schedule. And while it's true, for now, that these providers are able to be paid at 100% of the fee schedule through an allowance known as "incident to" billing, policymakers are looking at getting rid of those provisions and always paying these providers at 85% of the fee schedule.
The reality is that we’re in an increasingly challenging payment landscape across health care, as the health care system is in the midst of a paradigm shift away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs (value-based payment, or alternative payment models).
I’m hopeful this article gives some insight into what actually happened with the differential and how we've fought tooth and nail to improve the policy since its surprise appearance in federal legislation on February 5, 2018. Health care payment is a volatile landscape right now, and we have to keep striving for progress and working together.
David Harris, PTA, MBA, is vicepresident of integrations at Upstream Rehabilitation and chief delegate of the PTA Caucus.
The Five Things I've Learned as a Cash-Based Physical Therapy Practice Owner
By Aaron LeBauer, PT, DPT
What's the greatest number of patients you've treated in one day? My record is 43. I treated 43 patients one day, as a student. That's more than four people per hour during a 10-hour workday.
In that environment (and business model) I wasn't able to spend any quality time with my patients or treat them the way I thought was most effective. I wasn't able to work out, go to yoga, or even spend time with my wife. It was insane.
But it doesn't have to be this way.
Fast forward from my days as an exhausted student to today, where I am the proud owner of LeBauer Physical Therapy, a 100% cash-based practice in Greensboro, North Carolina. We help active people stay fit, healthy, and mobile without medications, injections, or surgery. And we do it without the time-consuming hassles from CMS or third-party payers who seem to constantly want to pay less for more.
For me, starting a cash-based practice wasn't a lifelong dream. I started a cash-based practice because I really did not feel that I had any other options.
I knew I was going to live here in Greensboro, and I looked around and thought, "Where can I get a job?" I didn't like working in a hospital; I didn't like skilled nursing. I knew my strengths were using my hands, doing soft tissue work, mobilization/manipulations, and spending time with patients to learn their stories and educate them. I didn't see a place here that was going to employ me and allow me to spend 45 minutes to an hour, one-on-one with patients, doing the type of physical therapy I wanted to practice.
My practice gives me the freedom to treat patients my way. It gives me freedom in my schedule. It gives me freedom to choose the quality of life I want. I get time! I can spend Monday and Friday afternoons with my family. I pick up my kids from school, hang out in the backyard, and grill some steaks.
Along the way, I've learned a ton and made plenty of mistakes. Here are five (of many) things I've learned as a cash-based business owner:
1. Mindset Is everything
To be successful, you've got to have the right mindset.
You are no longer worth what you earned for your salary or what the patient paid in copays each visit. You have to decide what you are worth, and then ask people to pay you that much. How much did it cost you to go to school? How much do you need each month to live and to operate your practice? What is the going rate for PT services? Be careful about charging too little or underselling your services. Find a price that's a little above your comfort zone and start there.
Once you start to change your mindset from a person who provides a treatment directed by someone else to a primary care provider who decides on the treatment, you will begin to thrive.
2. Low Overhead Is Key
It's important to have a low-overhead practice to minimize your expenses, especially when starting up, but also to maximize your profits in the long run.
The less you spend and the more you collect, the larger your profits. It's as simple as that! As a startup cash physical therapy practice owner, there are many ways you can leverage your dollars to get quality services in the creation and operation of your practice.
For instance, you can spend hundreds to design a logo and get business cards printed, or you can get 250 free business cards from VistaPrint and your logo created for $5 at Fiverr.
3. Give to Get
You've got to give in this business; when you give other people something they value first, especially if it's something they aren't expecting, they will feel compelled to give back to you.
Give your knowledge to others by creating educational programs and providing valuable resources such as newsletters and instructional videos. When you position yourself as the expert in your community by creating something of value that helps your "referral partners," potential patients will begin to seek out your advice and services when they need help, are hurt, or are injured.
But remember: Don't give anything when you expect something in return. Just give and watch what follows.
4. Live in Abundance
I'm going to say this right now: PTs need to stop putting each other down. We need to work together to lift everyone up. There is more than enough (money, land, patients, etc.) for everyone to succeed. It's known as an "abundance mindset," and it's crucial to our profession.
5. Market Directly to Patients
To have a successful practice means you need to market directly to patients. Patients are the consumers of our services — not physicians, insurance companies, or hospitals — and we have to connect with them.
Instead of spending money on traditional brand advertising, spend time and effort writing online articles and updating the content of your website to let patients know exactly how they will feel and what they will experience when they come to your office. Patients want to know what's in it for them, and they are searching on Google to find answers. You can be the one providing those answers.
Your patients should be the ones making the decision to come to you, so make it easy for them.
There you have it! Those are five things I've learned as a cash-based business owner. I hope you were able to see that opening a cash-based clinic isn't as daunting as it sounds. I did it first and made the mistakes so you wouldn't have to.
Aaron LeBauer helps physical therapists scale their time, income, and impact without relying on insurance. He's the host of The CashPT Lunch Hour Podcast, author of The CashPT Blueprint, and founder of The CashPT Nation Facebook group. Contact him at www.AaronLeBauer.com.