A Brave New Profession

I’ve been in a little bit of a dilemma this past week. A couple years ago I used to post blogs regularly and have heard from many people how much they would like for me to return to that schedule (Hi Mom!). I have spent the last seven months getting my professional life in better order so I can start doing that more – sold my clinic, recorded my weekend course, organized and delegated a lot of my initiatives within the AASPT, reduced my clinical responsibilities, reduced my podcast load, etc. I had organized everything so that I could start posting things again in mid-March/early April.

And then COVID-19 exploded.

No one wants to read about the importance of a quad index when they are worried about their next paycheck or whether or not they will be a major vector of transmission for their community. There is not much I can say about the current times other than that we should be encouraging everyone to stay at home while our profession rolls up its sleeves and supports the global healthcare system in any way we are called upon.

In the meantime…

In the meantime, what I can talk about right now is the future of who we are as a profession. A lot of what I’m going to talk about here is from the perspective of the US healthcare model, but those of you in other countries may find it gets you thinking of ways to make your own model better.

We as a profession were caught flatfooted by this. Many of our leaders immediately recognized that the most important part of our jobs as PTs could easily be done via telemedicine: Advising, supporting, educating, etc. – what I will collectively call “consultation”. What we quickly realized is that our third-party payers do not truly see us as providers of these things.

We are defined by our “treatments”

The reason that we were not getting reimbursed by third party payers is that they see us as a profession who physically does things to people. We have always been reimbursed for what is called “treatment”. Even an exercise code (97110) essentially requires that the patient DO the exercise for that entire time. We all know that the most important part of that code is the education component. This includes program design and modification as presentation changes. Just about ALL of this can be done via telemedicine. But it turns out that many of our third-party payers didn’t recognize this before.

Although some parts of our profession have been pushing for this change, a very vocal part of our profession has been fighting for reimbursement coding around interventions like dry needling and manipulations. We have been saying, “We need to be able to bill for more things that we can do to patients in the clinic!”

Play the game

We all know the game we have to play. I often joke with my patients that we need to keep moving so we can keep talking. But often times it would be better to sit down with a patient and talk about ways to integrate a home program into their chaotic life schedule. To talk about concerns regarding alternative explanations that they saw online. To discuss a long-term action plan that needs several sessions to teach and implement for true self-management. This becomes difficult to code honestly and ethically.

Sure, some insurances are happy to pay for this time billed under the code related to the component being discussed (97110, 97112, 97530, etc). But many simply say, “Whatever, ‘doctor’! (Read in ‘OK Boomer’ voice.) Just do the intervention to the patient as prescribed. If you’re not physically doing, we’re not paying. Dance, monkey. DANCE!” And therefore, with this mindset, what we do is not considered achievable via telemedicine to them.

Pay us for our TIME

Another problem is the reimbursement. Why should I get paid more for discussing a neuro re-education program over a therapeutic exercise program? More skilled? More impact? More cost to the clinic? I would argue “No” to all of it. The real question should be, “Does this require the brain of a licensed PT?” If the answer is yes, then reimburse them for their time if they can justify it. Full stop.

This is similar to what physicians bill as “Evaluation and Management” or E/M codes. Bill for the evaluation visit, then bill for your “case management time” during follow up visits. You can still bill other codes but getting us a better “case management time” code and then fighting for a respectable reimbursement rate should be the prime focus of our fight with third-party payers, in my opinion.

Pay us for our equipment use

The other part of what we bill for is the use of our space and equipment. But why is this linked to the intervention instead of the equipment? If I do exercise with someone on a $10 physioball for 15 minutes I get paid exactly the same as I do for doing exercise for 15 minutes on a $50,000 isokinetic machine. I’m not saying that everyone should run out and buy isokinetic machines, but the current model in no way incentivizes investment in progressive innovation. In other words, I get paid the same working in a single room with a couple cheap dumbbells as I do in a state-of-the-art facility.

Accurate reimbursement

Let’s go back to the physician model. When you get surgery, your insurance pays the surgeon their own fee, the anesthesiologist their own fee, and the facility their own fee. If the surgeon uses a more expensive device for the procedure, they add an upcharge for the use of that device. Of course they must justify it, but at least they can bill for it.

And here is the beauty of it. There is a lot that a PT can do with creativity and some cheap equipment from around the house. Let them get reimbursed for their time and limited equipment. But when the patient needs a test on an isokinetic machine, let them refer the patient to someone like me who would get reimbursed THE SAME for their time, but much more for the use of their highly specialized equipment. As opposed to now where we as a society are overpaying for the first visit while underpaying for the second.

Now as the owner of that expensive equipment, let me go to bat with a third-party payer to justify paying for that test at a regular interval with, for example, an ACLR patient. This is exactly what we see in the surgical world. “I know you spent a lot of money on that fancy surgical robot assistant but show us that it matters, or we won’t pay the extra fee!” Perfectly fair. But at least they can fight for these issues individually.

Incentives matter

Imagine this for a moment. You get paid more if you use heavy weights (they cost more) instead of light weights. You get paid more for using a dynamometer than for using a manual muscle test. It drives us to be better.

Again, justification matters as well. For example, I could see lots of reasons to use an isokinetic machine during a workout with a low back pain patient, but I’d have a hard time justifying it as being that much better than a heavy weight. In that case, using the isokinetic machine would get reimbursed as heavy weight use.

Telemedicine

And this brings me back to telemedicine. The patient isn’t using my equipment, just my time. So that is what I would get reimbursed for. There is a lot that we can provide here. A lot of my non-elite athlete population hate to take time out of their busy day, taking time off their hectic work schedule to come to a PT session. With telemedicine they can do it right from their desk at work. Even an hourly employee can do a quick session on their smartphone during their 15-minute morning break. Access goes up, way up!

SIDE NOTE: You ever work at a clinic where your entire patient population seems like they have little else to do with their day?

But what if they need equipment to do their program?

Well then the insurance company has a choice to make: Pay for the use of MY equipment or pay for the patient to have access to the necessary equipment elsewhere. Maybe this is reimbursing the patient for a physioball and a couple dumbbells. Maybe this is paying for a membership at a gym. Maybe this is paying my PT clinic for access to my equipment without direct supervision, if I decided to offer that. The point here is that this is a separate question from the skilled interface of the PT.

This looks different

Yes. Yes it does. The PT gets paid for their time, in person or remotely. Their PTA would get also paid (a little less) for their time – just like the time for a physician’s assistant (PA). The clinic owner gets paid for their equipment investments. The provider gets a lot more control over costs.

Sure, there are potential problems. If the clinic owner just invested in a balance assessment platform, for example, they are going to want it getting used and billed for every patient. But this is where all of us in the profession work together; researchers, clinicians, administrators, educators, advocates, etc.

If research unequivocally shows that the balance assessment platform is a game changer for “Diagnosis X” our educators can teach it in the schools and our advocates can lobby the third-party payers to cover it. If third-party payers announce that they will pay for its use, and your clinic sees a lot of “Diagnosis X”, this would incentivize your clinic owner/administrator to invest in the evidence-based resource.

Conversely, if the research shows no huge benefit from, say, laser therapy for “Diagnosis X” giving the insurance companies reasons not to pay for it, your owner won’t waste their money on the device.

You can see that this separates who we are as professionals from for who we are as “people who physically do things to people”.

The COVID-19 pandemic is swinging a large sledgehammer to a lot of institutions right now. Maybe when we come out of this we can become better for it in the end. The other thing that should be apparent from all of this is that we, as a profession, have a lot of growing up to do.

In summary…

• Dance, monkey! DANCE!
• Pay for my time
• Separately pay for using my equipment
• The future is now
• The profession needs to grow up

As for COVID-19, make sure to take care of yourself, your family, and your community!