Innovating physical therapist practice in end of life care.
By Karen Mueller, PT, PhD, DPT; Richard Briggs, PT, MA; Valerie Carter, PT, DPT NCS; and Christopher Wilson, PT, DScPT, DPT, GCS
In the recent past, healthcare initiatives such as the Institute for Healthcare Improvement’s (IHI) Triple Aim and the American Physical Therapy Association’s Vision Statement have identified “improvement of the healthcare experience” as a benchmark of patient centered care. These initiatives invite every stakeholder in the healthcare system to improve the needs of all populations through value driven outcomes.
Now, as the cohort of 70 million baby boomers moves towards end of life, we can no longer afford to ignore the increasing needs of those with severe, life threatening conditions. Many such persons undergo costly and futile interventions to the point where 25 percent of Medicare expenditures occur in the last year of life 1 Consider this scenario from one of our patients.
Jake, 65, had recently retired from his position as the manager of a large restaurant supply company, and his wife Sharon was enjoying her role as grandmother of five. The couple had just sold their home were planning to travel across the country in their mobile RV. One week before their departure, they were dining with friends, and Jake noted that he seemed to be slurring his words. A few days later, his adult son jokingly asked if Jake was intoxicated. Within the next two weeks, Jake’s slurring became more pronounced, and he also began to have difficulty with right hand dexterity. Jake visited his primary care physician who then sent him to a neurologist. An EMG confirmed Bulbar onset ALS. Now with his life upended, Jake found himself blindly navigating the bewildering miasma of our health care system. He and Sharon were exasperated by the endless repetition of his history to every provider, none of whom communicated with the other. His bi-pap delivery was delayed for three months by the inexplicable “loss” of the required paperwork. When the device finally arrived, improper settings led to respiratory complications and a costly hospitalization. No longer able to swallow without the risk of aspiration, Jake underwent placement of a feeding tube. By the time he was admitted to hospice, his finger flexors were severely contracted and he was in constant pain from muscle spasms. Throughout the six months of his disease course, not one of his providers mentioned the need for physical therapy intervention.
Jake’s case describes a common scenario in our fragmented health care system, illustrating the need for coordinated end of life care. Such intervention should ideally begin at the point of diagnosis with timely referral to a palliative care program. According to the National Consensus Project for Quality Palliative Care palliative care is defined as “patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering…in conditions where cure or reversibility is a realistic goal, but the conditions themselves and their treatments pose significant burdens and result in poor quality of life,”2
Palliative care is ideally provided throughout the continuum of illness in order to facilitate patient/family autonomy, quality of life, access to information, and choice of care. Palliative care programs also help patients to coordinate their care, to understand their condition, and to cope with related physical, emotional, and psychological distress. Payment for services rendered is the same as that for any other health related treatment.
Had Jake been involved in a palliative care program, he would have received timely and participation enhancing interventions, including those from a physical therapist. Most importantly, referral to a palliative care program would have prevented his costly and disabling complications.
The following paragraphs will describe current innovations in physical therapist practice in the population of those with life threatening disease as well as those at end of life.
Hospital Based Palliative Care
Hospitals and integrated health care systems are rapidly developing and solidifying comprehensive palliative care programs which are generally interdisciplinary in nature. The goals of these palliative care programs are to decrease readmissions and provide proactive, holistic care to avoid undue overutilization of acute care services and concurrently optimizing a patient’s remaining quality of life and safety.
Palliative care consultations have documented marked savings during hospital admissions. Due to various Affordable Care Act provisions including Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO)s, hospitals are incentivized to provide integrated services for chronically ill individuals.
Especially in rural or underserved areas, hospitals may be looking to partner with private clinics to help provide programs and services, especially as they relate to keeping an individual with a chronic illness from having an unwarranted readmission. In addition to traditional intervention-based physical therapy care, programs such as exercise and wellness sessions, family ergonomic training sessions, and fall and balance clinics are a few examples of possible collaborative offerings for palliative care patients within the private practice setting. As these services are generally found to be a valued service to patients and families, there may be opportunity for out-of-pocket payment in the circumstances that insurance coverage is not feasible.
In providing care for patients who have chronic illness or in palliative care, it is important to monitor the patient for early signs of medical re-exacerbation. Assessment of vital signs, gait speed, and other functional measures should be taken at baseline and at frequent, regular intervals with proactive communication to care providers. Often a hospital system providing condition-specific chronic disease management has a nurse navigator or other primary provider who supports these individuals across the continuum of care. This person may be an appropriate first contact if a medical exacerbation is suspected and intervention warranted.
Hospice provides palliative care for persons who have been certified by a physician to have a probable life expectancy of six months or less. People who receive hospice elect to no longer receive curative treatment for their underlying disease. The Medicare hospice benefit provides coverage for the comprehensive management of the hospice diagnosis and symptoms through medications, in-home nursing care, other disciplines and equipment.
Hospice care is provided in the homes of nearly 70 percent of the 1.6 million people receiving services annually 3. Medicare’s Conditions of Participation mandate that physical therapy services must be made available and provided according to accepted standards of practice 4 Nationally, agencies demonstrate wide variances in actual utilization, although physical therapy can be a strong organizational asset that enhances quality of life, patient satisfaction, caregiver safety, and market positioning for this underserved niche.
While some hospices hire physical therapy staff, many contract this service with private practice providers. Physical therapists who practice in hospice must be prepared to meet the needs of the patient and family with a realistic palliative approach, while recognizing the organization’s fiscal concerns in managing a per diem reimbursement rate of $160 daily for staff, medications, and equipment.
Five palliative models of care have been developed for this practice niche 5.
Rehab Light can be applied to reach goals of improved strength and function with graduated intensity and decreased frequency (weekly to biweekly), and is appropriate for new patients who are debilitated from treatment and disease effects, yet hopeful of gradual short-term improvement despite their prognosis of less than six months.
Case Management and Skilled Maintenance are models that provide oversight of physical status and functional mobility with intermittent reassessment, patient intervention, and family training to assure safety and independence, again with a variable and lower frequency than traditional rehabilitation. Their basis is from Medicare Home Health Guidelines and has been affirmed by the recent Jimmo vs. Sibelius Federal court findings. Rehabilitation in Reverse is the predominant model with patients declining in function over time, where physical therapy intervention provides skilled training to patient and caregivers as performance status decreases to maximize safety, independence, and family autonomy at each new level through the natural end of life process. Supportive Care includes comfort measures for pain management and massage to control edema, as well as the psycho-social-spiritual support that underlies all hospice and palliative care.
A responsive physical therapist will optimize communication with the interdisciplinary team. Providing feedback to referring staff is a basis for collaborative practice in meeting end of life goals, as well as identifying both ongoing care needs and future referral indications. The challenges of visit timing and variable frequencies must be met for patients with fragile and changing health and mobility issues in order to develop a successful hospice practice.
Considerations for Practice
Physical therapy intervention is an important aspect of the comprehensive management of a person with a life threatening serious disease, whether in palliative care or hospice settings. The physical therapist must be cognizant of patient disease process and severity as these will guide intervention. For example, the application of active or passive upper and lower trunk rotation is critical for persons in end stage Parkinson disease (PD) in order to reduce the severe rigidity and/or dystonia that occur in the later stages of this disease. As a result of optimal range of motion, movement quality, circulation and respiration quality can be enhanced.
There are few studies exploring the incidence and intensity of pain in persons with late stage neurodegenerative disease such as Multiple Sclerosis, PD, or ALS, however, reports from patients with these diseases suggest that it is a disabling symptom, similar to end stage cancer. For example, patients with PD often experience severe pain from dystonia in their feet and toes which limit balance and gait. Interventions such as interlacing fingers between the patient’s toes, massage, toe stretches with overpressure and/or weight bearing pressure and application of toe spreading socks can impact sleep and movement quality in the end stages of life.
Cognitive issues are also of concern in persons with severe disease. Persons with Multiple Sclerosis (MS), may demonstrate euphoria, leading them to misjudge the level of actual functional ability and pain, and contributing to lack of safety.
As physical therapists, we must advocate improved quality and quantity of functional mobility along with reduced levels of pain in the late stages of a disease. Thus, physical therapists must be be mindful of the specific complications and needs that arise along the disease continuum. Physical therapists must advocate a movement based approach to the improvement of symptoms from diagnosis until death, using outcome measures to demonstrate outcomes. Finally, patient and family education about the disease process and targeted strategies to manage symptoms add to the value to our interventions while improving patient quality of life.
The opportunity has never been greater to affect innovative practice approaches in end of life care. In order to prepare, we offer the following recommendations.
- Regardless of practice setting or location, physical therapists should be aware of palliative care programs in their area as well as associations which provide support to seriously ill patients. Physical therapists should take a prominent role in collaborating care and demonstrating value in healthcare systems.
- Physical therapists who treat patients with severe, life threatening disease, should inquire whether an advance directive is in place. There is evidence that the presence of an advanced directive saves healthcare costs by making patient desires explicit. Physical therapists can provide interventions around advanced directives which improve quality of life.
- Physical therapists must be prepared to demonstrate the value of their interventions in reducing 30 day readmission rates in hospitals, in reducing the need for pain medications and improving function, even at end of life. The selection of appropriate outcome measures will be imperative for the success of this initiative.
1. Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010 Apr;45(2):565-76 Accessed July 2016
2. The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines for Quality Palliative Care 3rd edition 2013. http://www.nationalconsensusproject.org/Guidelines_Download2.aspx Accessed July 2016
3. National Hospice and Palliative Care Organization Facts and Figures: Hospice Care in America 2014 Edition.
4. Federal Register, June 5, 2008. Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Part 418. Medicare and Medicaid Programs: Hospice Conditions of Participation; Final Rule.
5. Briggs R. Clinical Decision Making for Physical Therapists in Patient-Centered End-of-Life Care. Topics in Geriatric Rehabilitation. 2011; 27(1): 10-17).
Karen Mueller, PT, PhD, DPT, is a professor in the program in physical therapy at Northern Arizona University in Flagstaff, Arizona. She is the current chair of the APTA Oncology Section Hospice and Palliative Care Special Interest Group and a member of Rehabilitation Therapy Steering Committee of the National Hospice and Palliative Care Organzation. She can be reached at Karen.Mueller@nau.edu.
Richard Briggs, PT, MA, has had a clinical practice in hospice and palliative care for 30 years. He is Adjunct Faculty at California State University Sacramento and is a clinical faculty for MedBridge Education. Rich is past Chair of the NHPCO Allied Therapy section and founding chair of the APTA Hospice and Palliative Care Special Interest Group.
Valerie Carter, PT, DPT, NCS, is an associate clinical professor in the program in physical therapy at Northern Arizona University where she teaches content related to neurologic rehabilitation, geriatrics, and therapeutic intervention. Dr. Carter has presented and published extensively in the area of life long management of chronic neurodegenerative disease.
Christopher Wilson, PT, DScPT, DPT, GCS, is an assistant professor in the program in physical therapy at Oakland University in Rochester, Michigan. He is also coordinator of clinical education at Beaumont Hospital in Troy, Michigan. Dr. Wilson is currently serving as the vice chair of the APTA Oncology Section Hospice and Palliative Care Special Interest Group and Hospice/Palliative Coordinator for the World Confederation for Physical Therapy Oncology, HIV/AIDS, and Palliative Care Network.
The vital signs of a healthy business culture.
By Walt Porter, MPT, DPT, CEAS
It is no secret that the health care industry is undergoing major change, and formidable new challenges keep appearing from every direction. Implementing ICD-10 into practice and adapting to changes associated with the Affordable Care Act are two topical examples. More broadly, as our baby boomer population continues to age, hospitals are working to vertically integrate, and insurance groups are consolidating to prepare for the future. What is exciting is that with change come opportunities, if you are able to spot them and ready to seize them.
In these unsettled and unsettling conditions, one of the must-haves for success—not to mention survival—is a positive and compelling business culture. Dealing with the outside world is a whole lot simpler when, within the company, everybody is in sync with values and on board with goals.
Of course, from the Fortune 500 to the corner store, no two companies are exactly alike, and every business runs its own version of business culture. Scholars of business continue to define and refine the concept. For many, the wellspring of a company’s culture lies in its core mission, vision, and values—or at least, it should.
Harvard’s John Coleman, for example, identifies the six components of a great corporate culture as follows: vision to guide a company’s values and provide it with purpose; values that offer guidelines on the behaviors and mindsets needed to achieve the vision; practices, whereby values are baked into the operating principles of daily life in the firm; people who share and will strive for the same values; a narrative that crafts the company’s history into the ongoing development of its culture; and place, which through geography, architecture, and design impacts values and behaviors and so helps to shape culture.1 It is interesting to apply such analysis to your own circumstances.
Another way to monitor your business culture in action is to ask if it is unafraid of change, provides opportunity and motivation, provides stability and security, engages all of its members/employees, leads by example, is clear and appealing to external audiences, and reflects and reaches out to its community.
The more positive your answers, the more likely you are living up to your mission, vision, and values. For sure, when esprit de corps is high, a company’s energies can be focused on what it is really there to do—serve its customers, grow its people, support its community, and fulfill its mission. Another commentator, Michael C. Mankins, puts it like this: “Culture is the glue that binds an organization together and it is the hardest thing for competitors to copy,”2 creating ongoing competitive advantage for your company.
If its internal culture is not defined, embraced, practiced, and nurtured, uncertainty undermines performance, morale, and the company’s ability to attract and retain the best people. Certain brands are known for the strength of their business cultures that have been tested and proven in action during good times and others. These are companies with a clear sense of what they stand for and where they are going and with an inclusive approach to employees. They create workplaces where everybody feels engaged and that they can make a difference. Consider a few examples:
“You are part of something much bigger than you, it is not something you need to blog about to satisfy your ego,” a former Apple employee said.
As renowned leadership analysts James Collins and Jerry Porras observed two decades ago, “The Walt Disney Company’s core values of imagination and wholesomeness stem not from market requirements but from the founder’s inner belief that imagination and wholesomeness should be nurtured for their own sake.”
At the Gore Company (Gore-Tex), associates (rather than employees) are guided by the principles of fairness, freedom, commitment, and consultation. “What can you change?” the company asks.
Toms Shoes, with its One-for-One business model, offers employment with a built-in feel-good factor and the opportunity to put your social conscience to work.
Ride a Southwest Airlines flight and you get a sense of the upbeat, employee-centric spirit that has given the company its distinctive and successful presence.
All of these companies are driven by powerful internal cultures based on values and standards that are firmly established and universally accepted, with codes of behavior that are embraced rather than imposed. Each in its own way offers an example of what can happen when you get your business on course and stay the course as a team from top to bottom—as a team, that is critical . . . a team of individual talents eagerly collaborating for a collective purpose. Members of a successful team respect each other, work for each other, and strive unceasingly for their cause. How does a company best identify ability and nurture it, channel, and coordinate it for the good of all parties? How does it continue to strengthen the fabric of its business culture? Abstract-sounding questions with real significance on a daily basis.
In the physical rehabilitation industry as in every sphere of activity, we are all looking for answers. At BenchMark Rehab Partners we think a lot about how to fulfill our mission, which is “to inspire and empower people to reach their full potential.” Our vision, “by consistently exceeding expectations, we passionately strive to be the outpatient rehabilitation provider, employer, and partner of choice,” along with our mission and our core values, drive us as a company. We ensure as we grow in size that we stay personal in our approach and stay true to our founding goal of providing every patient with access to care from world-class clinicians. We constantly seek to foster everything that is good about our culture and upgrade anything else. We aspire to turn ideas with potential into programs and projects, monitor the results, and make adjustments as necessary.
We are also firm believers in John C. Maxwell’s dictum that “Small disciplines repeated with consistency every day lead to great achievements gained slowly over time.”4 As we build our company, we keep in mind the recruiting philosophy of Herb Kelleher in growing Southwest Airlines: “We will hire someone with less experience, less education, and less expertise, than someone who has more of these things and a rotten attitude. Because we can train people. We can teach people how to lead. We can teach people how to provide customer service. But we can’t change their DNA.”5
1. Coleman J, Gulati D, Segovia W. Passion & Purpose: Stories from the Best and Brightest Young Leaders. Boston, MA: Harvard Business Press; 2012.
2. Mankins M. The defining elements of a winning culture. Harvard Business Review. https://hbr.org/2013/12/the-definitive-elements-of-a-winning-culture. Posted December 19, 2013. Accessed August 10, 2015.
3. Collins J, Porras, J. Building your company’s vision. Harvard Business Review 74:5 https://hbr.org/1996/09/building-your-companys-vision. Accessed August 12, 2015.
4. Maxwell J. The 15 Invaluable Laws of Growth. New York, NY; Hachette Book Group; 2012.
5. Kelleher, H. 8 Herb Kelleher quotes that will teach you everything you need to know about life. www.freeenterprise.com/8-herb-kelleher-quotes-will-teach-you-everything-you-need-to-know-about-life. Posted March 21, 2014. Accessed August 16, 2015.
Walt Porter, MPT, DPT, CEAS, is a PPS member and senior vice president of operations for BenchMark Rehab Partners. He can be reached at firstname.lastname@example.org.
Quality metrics affect payments in CJR, do you know the tools?
By Craig Johnson, PT, MBA
The new Comprehensive Care for Joint Replacement (CJR) program was rolled out on April 1, 2016, by the Centers for Medicare & Medicaid Services (CMS) (see previous Impact articles on the CJR). In this bundled payment model, quality measures play a big role in determining whether a convener receives a reconciliation payment or makes a repayment to CMS. While you might not be involved in a CJR program, this article provides you an opportunity to learn about the quality measures in CJR, but for physical therapy (PT) providers wishing to collaborate with hospitals it is critical to understand the quality measures. Private practice PTs are allowed to negotiate “collaborator” agreements and share in up/downside risk with the hospital “convener.” Practice owners must not only understand their costs, but also understand the quality measures that will impact payment adjustment. This article will take a closer look at the quality measures used in the CJR. You will learn about the mandatory and voluntary quality measure tools, the timing of measure capture, and how it affects payment adjustment.
Required Quality Measures
There are two required quality measures in the CJR bundle. The first is the hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) (NQF #1550). The measure outcome is the rate of complications occurring after THA and/or TKA surgical procedures during a 90-day period following the date of the index admission for a specific hospital. One or more of the following complications are considered in the measure:
- acute myocardial infarction
- pneumonia, or sepsis/septicemia within 7 days of admission
- surgical site bleeding, pulmonary embolism, or death within 30 days of admission
- mechanical complications, periprosthetic joint infection, or wound infection within 90 days of admission
While this measure is currently collected by hospitals, physical therapists can play a significant role in monitoring complications during post-op rehabilitation that might lead to readmission or additional costs.
The second mandated quality measure is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166). The HCAHPS Survey measures patient perceptions of their hospital experience. The HCAHPS Survey asks recently discharged adult patients 32 questions about aspects of their hospital experience. The core of the survey contains 21 items that ask “how often” or whether patients experienced a critical aspect of hospital care. Eleven HCAHPS measures (seven composite measures, two individual items, and two global items) are publicly reported on the Hospital Compare website: www.hospitalcompare.hhs.gov/.
The seven composite measures summarize the following:
- how well doctors communicate with patients.
- how well nurses communicate with patients.
- how responsive hospital staff are to patients’ needs.
- how well hospital staff help patients manage pain.
- how well the staff communicates with patients about medicines.
- whether key information is provided at discharge.
- how well the patient was prepared for the transition to posthospital care.
Voluntary Quality Measures
Voluntary quality measures THA/TKA PRO-PM (patient-reported outcomes and performance measures) in years 1–3 are anticipated to be integrated as a mandatory measure in years 4 and 5, with details to be proposed during future rulemaking. CMS is interested in PROs and performance measures because it allows them to assess postoperative outcomes and analyze data in order to:
- Determine a narrow set of risk factors for statistical risk adjustment of patient-reported outcomes.
- Examine the differences in hospital performance related to different components in the patient-reported outcomes (such as functional status, pain, etc.) for statistical modeling for risk adjustment.
- Evaluate the reliability of the patient-reported outcome measure.
- Examine and test validity of the patient-reported outcome measure in the risk adjustment model using testing methods such as face validity testing with national experts compared to similar results based on other data sources.
The challenge, as you see in the table, is the timing of measure capture, particularly at 270 and 365 days post-op. Ultimately the responsibility lies with the hospital convener to report quality scores; however, physical therapists in private practice can demonstrate value by understanding the measures and where they can contribute.
PROMIS, the Patient-Reported Outcomes Measurement Information System, measures physical, mental, and social health and can be used across chronic conditionsii. Domain definitions include physical function, fatigue, pain, emotional distress (including depression, anxiety, and anger), social health (including social function and social support), and global health. PROMIS is a measure whose scores can be compared across diseases and conditions, thus capturing patient global health.
The VR (Veterans RAND)-12 is a 12-question survey that assesses similar domains and summarizes the score using Physical Health Summary Measure and Mental Health Summary Measure scores. The CJR regulations for voluntary reporting require collection of either the PROMIS-Global or VR-12.
HOOS and KOOS, Hip Injury and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score, collects data on five hip- or knee-specific patient-reported outcomes. Five domains captured in either HOOS or KOOS include: (1) pain; (2) symptoms: other symptoms such as swelling, restricted range of motion and mechanical symptoms; (3) ADL: disability on the level of daily activities; (4) sport/rec: disability on a level physically more demanding than activities of daily living; (5) QOL: quality of life, mental and social aspects such as awareness and lifestyle changes.iii Items for HOOS and KOOS were selected based on: (1) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), version 3.0; (2) a literature review; (3) an expert panel (patients referred to physical therapy for knee injuries, orthopedic surgeons, and physical therapists from Sweden and the U.S.); and (4) a pilot study of two questionnaires (one for symptoms of ACL injury, one for symptoms of OA) in individuals with posttraumatic OA.iv
Additional PM (performance management) measures include body mass index (BMI); pain; quantified spinal pain; objective measures of motion, strength, and gait; congenital joint conditions; and health literacy. These PRO-PM measures should be familiar measures to physical therapists. If not, you should become familiar with these measures that will effect payment.
Quality Composite Score
A composite quality score is computed for each participant hospital, which summarizes the hospital’s level of quality performance and improvement on specified quality measures. The composite quality score assigns different weights to each of the measures:
- 50 percent for the hospital-level RSCR following elective primary THA and/or TKA (NQF #1550)
- 40 percent for the HCAHPS Survey measure (NQF #0166)
- percent for the THA/TKA voluntary patient-reported outcomes data submission. Based on quality scores, each hospital is placed in one of four levels.
The discount for all participant hospitals is 3.0 percent, which will be adjusted by the quality composite score; thus hospitals will have either less repayment responsibility (that is, the quality incentive payment will offset a portion of their repayment responsibility) or receive a higher payment (that is, the quality incentive payment would add to the reconciliation payment) at reconciliation. Measure for measure, quality metrics will be used in bundled models of value-based payment. Now is an excellent time to learn about the measures and understand how your hospital partner is impacted by the scores before you negotiate.
iCMMI Comprehensive Care for Joint Replacement Model: Quality Measures, Voluntary Data, Public Reporting Processes for Preview Reports. https://innovation.cms.gov/initiatives/cjr. Accessed April 20, 2016.
iiPROMIS Dynamic Tools to Measure Health Outcomes from the Patient Perspective www.nihpromis.org/faqs. Accessed May 9, 2016.
iiiPhysical Performance Measures, OARSI set of recommended physical performace measures for hip and knee osteoarthritis. www.koos.nu/index.html. Accessed May 9, 2016.
ivRoos, E. M. and L. S. Lohmander (2003). “Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis.” Health Qual Life Outcomes 1: 64.
1. Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/cjr. Accessed May 4, 2016.
2. Federal Register. Medicare Program; Comprehensive Care for Joint Replacement Payment Model Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. November 24, 2015. www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals. Accessed April 20, 2016.
3. American Physical Therapy Association. Comprehensive Care for Joint Replacement Model (CJR). www.apta.org/CJR/. Accessed May 7, 2016.
Craig Johnson, PT, MBA, is a PPS member and partner of Therapy Partners, Inc. in Minnesota. He can be reached at email@example.com.
By Terry C. Brown, PT, DPT
It is early August and once again time to write to all who read this great magazine. What is on my mind today and what has already had a vast amount of work put into it is Private Practice Section (PPS) Annual Conference.
As we prepare for this year’s extravaganza in Las Vegas, I can’t help but look back to how this event has evolved and what it has meant to my career. My first PPS annual conference was in 1992. I went looking for something different. I was not new to working in a private practice but was brand new to managing one. I had no idea what I was doing, but knew I needed help. I had suddenly found out that being a skilled manual therapist did not necessarily relate to running a practice. I had been quite involved in American Physical Therapy Association (APTA) as a chapter president and had even served on several committees, but I was not finding the help I needed to tackle my new adventure. So, as a nervous young therapist, off I went to a world that appeared to me to be made up of giants who were out of my league, PPS members at the annual conference. I had not been there an hour when then president of PPS, Peter Towne, walked up and introduced himself. That’s all it took. I was hooked. I spent the next three days soaking up everything I could learn and meeting everyone who would give me the time of day. I went home with so many ideas and so much enthusiasm that my staff threatened to never let me go back again.
By the next year Peter had talked me into running for nominating committee. I lost the election but I met more really smart, innovative people who were willing to share their expertise and act as mentors to this young therapist who had nothing but questions. The path from 1992 to now is paved with so many friendships and so much sharing that I am truly blessed to have made this journey. I can honestly say that the success of my practice is directly related to my annual conference attendance.
My story is not unusual. Most PPS members who attend annual conference will have a similar one. Once you go it is very difficult to stay away. There is too much knowledge, sharing, education, and just plain good fun to miss. It is also the best investment that you will ever make in your practice—an all-inclusive conference with free meals and social time, vast and varied educational opportunities, and your ability to make contacts.
I’d say it’s a pretty safe bet that you can hit the jackpot at this year’s conference. See you in Vegas next month!
A big picture look at Revenue Cycle management and touches on the interconnected nature of the first point of patient contact through a paid claim.
By Eric Cardin, PT, MS
Revenue cycle management, a relatively mild term in the world of business jargon. It’s a simple yet important idea to look at the “management” of revenue. Physical therapy practice can be an emotionally and personally rewarding profession, but the obstacles between treatment and payment can be daunting. The term cycle implies a defined series of events or a routine that repeats itself, a cycle or pattern that is overtly and covertly tied together and the nature of which holds the key to successful management.
Visits x Charges x Accounts Receivable = Revenue (Income minus Expenses)
Simple, right? See a patient, charge for it, collect that money, pay the bills. Have something left over. Many businesses, including physical therapists in private practice, struggle or even fail by not digging deeper into what drives the factors in this basic equation for revenue cycle management.
Visits are revenue. No matter what metric you use, when you get to the bottom of the paper, visits drive the bus. Getting the patient in the door is an obvious first step but keeping them coming and growing the practice is the first and most important step. After all, there is no revenue cycle without revenue.
From the moment of first contact (phone intake, walk in, scheduling a neighbor for an evaluation on your phone—thank you, cloud-based electronic medical record (EMR)—while standing in line at the grocery store), the revenue cycle starts. So much of our ability to efficiently bill and collect revenue and manage cash flow is dependent on how well we collect information up front. “Clean” demographic information is the first obstacle we face in getting paid on time. Depending on the volume of your office, the ancillary staff you may or may not have, and the collection method, there are several “fail points.” Handwriting problems, typing errors, missed steps, and general lack of organization can and will delay a claim. It is very important to get the information from your client and get it into your billing/scheduling software in a quick and accurate manner. If you look at your turnaround time (time to get paid from the point you send out claim), you should be able to discern what the average is and also take note of what claims are rejected and why. Take note of the common errors and implement simple policy changes to reduce the rate of rejection. Your cash flow will thank you for it.
After you’ve efficiently and accurately collected demographic information and processed it without error, you still have some hurdles to overcome. Was there a referral in place? Was the patient authorized and/or do they have active insurance that will cover them during their entire episode of care? There are a few ways to go about this. One, you leave it to the consumer. It is their responsibility to know their coverage. Or two, you collect the necessary information at intake and you “trust, but verify.” There is usually a personal cost (doing it yourself) or actual payroll expense (paying someone to do it) in the time it takes to make sure all the referrals and authorizations are in order, but for a solo therapist with a full (30 to 40 hour) schedule of patients, for example, the effects on the bottom line are worth the up-front effort.
The unifying theme in the first factor of “Visits = Revenue” is the ability to collect information. The tie that binds the components together is a positive customer service experience. A pleasant phone call or face-to-face encounter that leaves your client with the feeling that you are helping them get registered, authorized, referred, and ready for what is usually their first physical therapy experience will go a long way to establish your office as the destination of choice for physical therapy. It is wise to remember that the most important marketing opportunity you have is the patient who is already in front of you. Creating an environment that helps the client heal and doing so in a way that creates a feeling that everyone in the office is helping them on their journey will only serve to grow your patient base and your bottom line.
Once you’ve seen the patient you’ve got more hurdles to jump through. What’s your payer mix, what are their coverage rules, what codes do they accept, and which ones pay well? The next factor in the equation for cycle management, “Charges,” is another important factor. Payer mix (what percentages of which insurers are paying you) should be a huge part of your due diligence prior to getting started. If you find yourself inundated with patients that have a low reimbursement rate, you might find it hard to stay in the black. Payer mix can be quite varied, and can change even from one town to the next. It is important to investigate who your patients may be, where they will come from, and who is insuring them before you decide where to practice. After you’ve made that decision, it is a good idea to routinely sample your payer mix and take note of where your bread is being buttered. Once you understand that, you can tailor your demographic collection and charge habits to maximize your revenue. As you understand payer mix, you will also find that it is important to stay on top of credentialing, continuing education (regarding coding/charges), and global changes to reimbursement. Visits x Charges = Revenue. If you have a multitherapist practice, get in the habit of sharing who pays what and what is well reimbursed and what is not. Even if they are not the practice owner, you will be surprised that they often do care that they are reimbursed appropriately. The cycle continues with or without you and your attention to detail is key. The only thing you stand to lose is money!
Now that you’ve created a positive customer service environment and efficiently and accurately collected patient demographics while understanding insurance rules and gotten the client better without going over the allotted visits—it’s time to collect your revenue. Visits x Charges x Accounts Receivable. It is important to note that this equation we use to describe the revenue cycle uses multipliers, not addition. This is done with the intention of creating an understanding that success or failure will move exponentially. Small mistakes or small victories will carry over quickly. If you are seeing a hundred patients a week or a thousand, then that is your multiple. One mistake repeated 100 times. Or one success repeated over and over. It is all connected and all part of the revenue cycle.
Accounts Receivable (AR) is a basic component of any business that allows their “product” to be taken or used with a promise of payment. Physical therapists in private practice face the delightful challenge of having varied payment methods, contractual adjustments to our fees, and limited ability to make changes. Again, there are options. Cash-only payment at time of service sounds appealing when you delve deep into third-party reimbursement, but for those of us not ready for that option we must soldier on and get on our AR. Since we know we’ve already collected accurate demographics and used our expensive billing software to send out “clean” claims, we can just sit back and watch the bank account swell. Right? Think again. The struggle is real and the cycle waits for no one.
Again, the tie that binds is customer service. Helping your client understand their benefit before they start physical therapy can seriously and positively affect your AR. Kindly let each patient know what their personal financial responsibility will be (copay) or could be (estimate their deductible) for their time in physical therapy and routinely remind them that their copayment, coinsurance, deductible, etc., is due, or will be due. Accept all forms of payment, remove all obstacles to “I forgot my [insert payment method here].” Create controls in the system to keep balances low and keep your consumer informed. Soft chasing them the same day in the front office is much easier and much more cost effective than bringing it up 90 to 120 days later. Start at the first point of contact with creating an understanding that you provide a service and that service has a cost. Too often we fall into the trap of the “helper/healer,” but have you ever tried to pay the utilities with good feelings?
Once the claims are out and awaiting payment, watch your rejections and Explanation of Benefits. Much of the payment process is automated and this has been to our benefit, but computers still can make errors and somewhere along the line someone is processing your claims who maybe—just maybe—isn’t having the best day and they just might let a charge slip through unpaid. If you are not managing this part of the cycle, there are plenty of ways to lose money. Pay attention to individual filing limits, coding rules, and coverage limitations. Bill your services as soon as you can, follow up as quickly as possible, and send out statements weekly (or more frequently if you can) to keep the cycle going and your cash flow strong. Bill the claim, correct the claim, rebill the claim. Keep the statements rolling.
Finally, you’ve collected demographics, charged appropriately, followed up on outstanding claims, and hopefully watched your bottom line grow. Revenue cycle management is constant. It begins with the first point of contact with every patient and ends with prompt and accurate payment. Tight controls, simple policies and procedures, and attention to detail should result in timely payment. Each practice should take a look at least quarterly at the components of the cycle. As time passes your data set grows, and you can see cause and effect and sharpen the parts of the cycle that lead to prompt, accurate payment.
Eric Cardin, PT, MS, is the executive director of South County Physical Therapy, Inc., which has six locations in western Massachusetts. He can be reached at firstname.lastname@example.org.