In reference to the overtreating thread (Full Version)

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ysumpt2006 -> In reference to the overtreating thread (November 13, 2007 10:34:09 PM)

I figured I would just add to that thread and reference what I have been going through lately, but it ended up being longer than I expected.

The "problems" at my place of employment have become "legendary".

My boss ordered an individual productivity meeting last week. He met with each clinician and asked what we could do to improve our productivity. Some clinicians suggested the "upping" of patients--seeing them for a certain amount of time and if they patient could "benefit"  from more therapy, he/she should be passed off to another clinician for 1-2 more units.

Also, I'm getting some flack from PTA's because I'm not treating exactly as the script suggested especially if I feel the patient would get as much benefit from less therapy--2 vs. 3 times per week and what not. They are used to therapists (more "seasoned" clinicians) who if a script is written for 3x/wk for 6 weeks, then they keep their patients for 18 visits, no matter what. This is fine if they are used to that, but then they go and "complain" to the other therapists and/or the boss (non-therapist) and "suggest" that I'm going against the doc or short changing patients because I am only seeing them twice a week. This is productivity based because they are presenting it to the boss as I would be more productive if kept those patients for a 3rd visit or that their productivity is down because I'm not giving them patients to meet the 3x/week that THEY think I have to treat the patient.

My usual billing is 3-4 units and mostly twice per week. I reserve 3x/week for post surgical/acute injuries and individuals I think need some extra care.

One of my co-workers had the gall to tell me I'm an new therapist and I will soon realize who needs what and how many days. It is a skill that I will learn, but it takes a long time. I may be a new therapist, but I've been working with people in this type of atmosphere for 15 years. I have better insight into what is best for people than a "typical" first year professional.

I could see if I was not getting great outcomes or my patients were not getting better, but I'm getting people better quicker and I am put in the positioin where I have to defend my treatment plans to PTA's who are too busy "running to the principal" to ask me my thoughts behind my treatment philosophy.

On one hand my boss is saying to get people better as best we can, but then suggests if 3x/week is an option, then use that 3 times because "our  numbers are a little down right now" and "it's like lost revenue". He's covering all of the bases.

He has also given me "permission" to speak to the PTA's regarding how I treat and why I treat the way I do. 

Thanks for being my sounding board.



ysumpt2006 -> RE: In reference to the overtreating thread (November 13, 2007 11:20:10 PM)

Any thoughts?



SJBird55 -> RE: In reference to the overtreating thread (November 13, 2007 11:24:35 PM)

Well, maybe what your boss needs to do is get out there and market.  He can't assume that every patient is going to have a 4-6 week course of PT with 3 visits/week. 

Why is he measuring productivity based on the number of visits a patient comes for an episode of care anyways?  That isn't "productivity."  What he needs to look at is the total number of billable units per day that are actually reimbursed.  He might consider looking at the procedural codes used... there are codes that are reimbursed at a higher rate than others - the modality codes have the lowest reimbursement amount.  What is being used to measure goals?  Just plain old goals or do you have valid and reliable standardized functional tools in place to help determine the level of function and the degree function is changing.  It is frowned upon to have a "plateau" for 4 weeks while a provider is thinking the patient can benefit with no substantial evidence of the benefit acquired.  Physicians just provide "suggestions" - physicians aren't going to be the ones getting reamed out for fraud or lack of skilled services or unnecessary services.  A PT has a license and a PT is the one designing the plan of care and the PT will be the one responsible. 

When numbers are down, that is not your problem.  When numbers are down, it is the time to assess the programs in place, the community and the needs of the community.  Numbers being down is NOT the reason in which to base frequency of visits.  You can alert him to the matter that if the facility were ever audited and it appeared that services were not deemed medically necessary that the facility could have some penalties/fines AND a takeback of money.  By practicing correctly and within guidelines and rules and regulations, in the long run, you are SAVING him money because the likelihood of an outside source determining that services were not required wouldn't occur.



orthotherapist -> RE: In reference to the overtreating thread (November 15, 2007 1:47:05 PM)

I think it was you on the US/OCS thread that was discussing this situation.  Non-clinical manager = no good at making clinical recommendations.  If your employer does not realize this things will not change.  It sounds as if you are a ethical clinician treating appropriately.  The other clinicians may have been this way but have been dragged down by poor leadership - stick to your guns and educate staff/administartion.  If they still do not see the light then jump ship when you can.

As a side note my last boss (clinical but sounds a lot like your boss) was just canned a few weeks ago.  Hospital administration must have finally realized all the issues that were going on.  Many were unethical (IMO).  They could never keep new graduates because they always bucked the trend that this hospital had in place much like you are.  Old grads that had been indoctrined (read brainwashed) just went along for the ride.  These tended to be mothers that were working to make a little extra $ once their kids started school again.  They were not your career minded therapists - for them it was a job.

Better times are ahead and change is good.  Just remember that it is your license which equals your livelihood. 



buckeye -> RE: In reference to the overtreating thread (November 15, 2007 6:38:08 PM)

Agree the situation you have is not great. Some non-therapist managers do not look at the level of professional judgement we should use. Too often, their thought is, "If the physician ordered it, we should do it." I have orthopedic surgeons and nurses who do not understand why I prefer not to have a first-day post-op 80+ year old patient with hip fracture and positive cardiac history not exercise if their hemoglobin is 8.2 g/dL.

If you are not leaving, take care of yourself. Talk to your patients and comunicate with the referral sources about your plan of care. Get a physician signature on your plan of care. In my opinion, most referrals that come with specific frequency, duration, modalities, etc. are more because of habit/tradition than from a working knowledge of what is best for the patient. The APTA Guide to Physical Therapist Practice leads us to think on our own by giving a typical range of visits over a period of time with the frequency of treatment determined by the therapist.

sjbird has great thoughts on the productivity part - this should be geared more to working the appropriate number of units, knowing what CPT codes are best for the situation, etc. If you are 'good' at what you do, you will have the patient safely return to function in a shorter period or with fewer visits (within parameters of tissue healing)

Many of my patients have some level of restricted insurance benefits - maybe only 20 PT visits per year. You cannot spend 9 to 12 visits just grinding out basic exercises and using passive modalities just because the physician wrote it on an order and the manager thinks it should be done.

Keep up your spirits - orthotherapist is correct. There are better times ahead for you.



l_a -> RE: In reference to the overtreating thread (February 8, 2008 1:52:50 PM)

hello SBJ,
I respect your opinion, what do you believe good goal for total units per day is without sacrificing pt care?

thanks.



buckeye -> RE: In reference to the overtreating thread (February 8, 2008 3:42:15 PM)

I will offer a basic answer - but I think you are correct in seeking advice from sjbird.

The number of units you can bill per day is limited primarily by how many hours (or more correctly 15-minute intervals) you work. There will be a point of mental or physical fatigue for you that will limit your ability to provide quality care. That number of units will vary considerably depending on the therapist's abilities and the types of patients being seen.

Perhaps the better question is not about total units per day but the number of people you are seeing simultaneously. The sacrifice in patient care occurs when you cannot spend time with the patient on movement reeducation, manual therapy, proprioception, teaching, etc. The ideal situation is one-to-one patient to therapist ratio - this generally provides the best opportunity for optimal patient outcome and clinic productivity. Of course, you can also have follow the passive modalities route and have high volume units per day - but is this the best course for your patients?

You can crunch numbers to look at dollar amounts for billing - the bean counters like to look at that type of productivity. The clinic should be financially sound or the doors cannot stay open. But it is possible to be profitable without  sacrificing patient care.



l_a -> RE: In reference to the overtreating thread (February 8, 2008 7:32:00 PM)

Thanks buckeye, I will try to be a little more specific. This is for an outpatient PT clinic in a normal 8hr day.

I agree with you. in any business the income has to be more than expences, or else you can't stay open. I'm just trying to get a sence of what people think is a fair number to achieve the correct balance of quality care, a godd employee, and a successfull clinic ( I know a large part of it is population, but I'm assuming there is an accepted range)

IMO we have to be carefull here. We are not like a car salesman (as an example) trying to upsell, where people are looking at their peer. This is what bothers me when a clinic tries to tell the therapist how long to keep a pt per visit (in terms of units per pt), or how many visits to keep a pt coming back.The people we see are putting their trust in us. If we say they need to come im 3x/wk for 3months for 2hrs each day, they are assuming that this is what are expert opinion is on how to get them better the fastest, not to pad the bottom line.

I reluctenlty posted this, bc I don't want to come accross as someone who is unrealistically idealistic. I am truly trying to achieve that balance, and feel that a forum where there are a great number of fellow professionals would help me get a better idea of where that is.



TexasOrtho -> RE: In reference to the overtreating thread (February 8, 2008 10:34:55 PM)

I'm probably hypersensitive to this issue.  I still believe we should be giving our patients the best care in the least amount of time.  Ideally this makes us efficient and places the least amount of strain on the patient's finances. 

There is the reality (as someone mentioned) that we have to run viable practices.  I work in a single-PT clinic (me!) and have averaged 15 patients per day over the last 3-6 months.  It wears me out sometimes, but it has forced me to really refine my practice. To me the lithmus test is the letter of the law - you must obey it without exception.  The rest is a combination of your ethics and comfort.

I never thought I would say it, but I can now treat 15 patients per day consistently with my tech who is degreed in exercise physiology and will be starting PT school herself soon.  The patients are happy, I obey the laws, practice ethically, and feel like I'm working hard to make sure they get the best care possible.

This process took time.  I used to refuse to see more than 12 patients per day because each patient deserved one hour of my "delicate genious".  Now I feel I can do this and feel good about my day at work.  Other PT's are different and I completely understand that, but this is where I'm at right now.



buckeye -> RE: In reference to the overtreating thread (February 11, 2008 9:57:09 AM)

Texas Ortho - I hope I did not overstate the notion of direct one-on-one treatment as being the only way to treat. I agree that it is possible to use qualified PT techs as an adjunct to treatment. Excellent point about following the rules/laws. I also respect the idea of giving optimal care with the least amount of dollars spent. I have physicians who think I undertreat because I may only see someone one or twice a week when doing basic exercises instead of three times per week.

l_a - Your answer may be elusive because of the many variables in treatment. If you have looked at the Guide to Physical Therapist Practice from the APTA, it offers a wide range of total number of visits over a wide range of duration and recommends the frequency of visits be determined by the physical therapist. The amount of time per visit can be based on what the patient needs and the availability of resources. Perhaps the staff at the clinic can sit down and discuss these issues with management - maybe there is common ground.



SJBird55 -> RE: In reference to the overtreating thread (February 11, 2008 2:19:05 PM)

If patient centered care is provided, the frequency of visits is determined upon the needs and resources available for that particular patient.  If patient centered care is provided, the time actually spent in the clinic is dependent upon the needs of the patient.  I don't like to look at visits/day because does every patient require the same intervention from me? 

In an 8 hour day, there is a business opportunity (within the rules and regualtions) to provide 32 one-on-one CPT codes.  I would also think of the level in which the codes are reimbursed AND whether you are truly being reimbursed for the codes utilized.  (With Medicare, for example, hot packs are bundled - you can tag the CPT for that procedure on your charge sheet, but Medicare doesn't reimburse for it.)  Modalities are reimbursed at very low levels, so is it really reasonable to just look at CPT codes/8 hour day or is there a better way?  You will get the most bang for you buck providing one-on-one procedural codes AND most of those codes are generally what I'd consider active participation codes and do tend to lead to effectiveness of treatment.  Productivity is also dependent on the tools provided for physical therapists to utilize.  Handwritten documentation versus electronic medical records may make a difference in productivity.  Also, you will have a mix of 97001 and 97002 codes - which are untimed codes when you look at the normal 8 hour working day for a physical therapist.  Most PTAs do not have a NPI, which means the claims for their services are submitted with the NPI of the supervising physical therapist - does your employer count those units as productive units because you are supervising the PTA? 

I suppose the easy answer is that if you as an individual physical therapist are billing out 32 one on one timed units/8 hour day, you are 100% productive.  Is this realistic?  No.  Life happens and there will be holes in your schedule for whatever reason.  I'd assume in an outpatient setting 80-90% productivity would be a great goal.  Mathematically, this would be 25.6 units to 28.8 units.  From a purely business perspective, you want to bill out 32 one on one timed units per day - the more efficient you can be along with maintaining good documentation and accurate documentation, the more closely you can actually maybe reach 32 units/8 hour day.



l_a -> RE: In reference to the overtreating thread (February 28, 2008 10:18:44 PM)

Thanks again for the responce.

We are expected to have 32+ units perday. 3.5+/pt & 12-16 visits per pt.

I have less of a problem with the 32/day than the other two.

I'll just keep doing what I think is ethical and deal with the consequences.



megspt -> RE: In reference to the overtreating thread (March 11, 2008 9:28:14 PM)

I guess I'm curious how ysumpt2006 has 15 yrs experience, but hasn't been a therapist that long. 

May be the PTAs are seeing/noticing something with your patients that he's not.  If I think a patient could only be seen 2x/wk, but they would prefer 3x, I'll have them schedule 3x/wk.  I'll ask them what they would prefer- I think it plays into the psychological factor of getting better and gives them some control over their treatment.



Kaden -> RE: In reference to the overtreating thread (March 11, 2008 11:06:38 PM)

megspt,

I think there is a fine line in giving you patient control over their treatment versus overtreating and over billing. If you think someone would benefit from 2x's a week then you should be seeing them 2 times a week.  More for the sake of psychological gain is nothing more than billing non essential services to the insurance company. 

If MDs thought this way they would go around ordering expensive imaging for all patients referred to therapy b/c it would make the patient feel better/more at ease and give them the idea they had more control over care.  I would hope you would agree that ordering a test costing thousands just to comfort a patient would be wrong.  Doing this with therapy is the same thing all be it on a smaller financial scale.



jlharris -> RE: In reference to the overtreating thread (March 11, 2008 11:12:49 PM)

quote:

If MDs thought this way they would go around ordering expensive imaging for all patients referred to therapy b/c it would make the patient feel better/more at ease and give them the idea they had more control over care.


Not funny but it is...I work with a large WC population, and that is how it seems to work.  "Defensive Medicine".  Might as well order the $2k MRI for a simple low back strain to avoid the 1 in 10000 pt that has bony metatises.



ysumpt2006 -> RE: In reference to the overtreating thread (March 12, 2008 11:44:43 AM)

quote:

ORIGINAL: megspt

I guess I'm curious how ysumpt2006 has 15 yrs experience, but hasn't been a therapist that long. 

May be the PTAs are seeing/noticing something with your patients that he's not.  If I think a patient could only be seen 2x/wk, but they would prefer 3x, I'll have them schedule 3x/wk.  I'll ask them what they would prefer- I think it plays into the psychological factor of getting better and gives them some control over their treatment.


I've been working in the exercise/health/sports medicine field for that long. I have two degrees in exercise physiology. I know how the body reacts to stresses and what it needs, believe me.

I'm not in the job to make people "feel good" or think they have complete autonomy in their care. If they knew what they needed, they wouldn't be in PT. My job is to make the clinical decisions based upon what I see in my interactions with them. I've battled patients and management who have tried to tell me how to do my job and I let them know that I know what I'm doing. Yes, I'm a little "green", but that doesn't mean that I'm new to the basics of PT. If I want people to take more control in their treatment I make sure they know that it is their job while they are injured to do their HEP to recover.

Recently, a patient felt the need to discuss her perceptions of not getting better with her PTA. He advised her that if she wasn't happy she should discuss it with our boss (non-PT manager). He read me the riot act saying I had to apologize to her for not seeing her 3x per week because she thought she was getting "shafted" on care. She couldn't see the results. Well, after talking to her, explaining what I was doing, she went back to her MD who released her from PT because she had reached the outcomes he wanted and she could do things she hadn't done in many, many years. So it seems I knew what I was doing after all.

I don't know everything, but my outcomes and results speak for themselves. My patients are getting better quicker and with less expense to them (via co-pays) and the insurance companies. Isn't that what we are supposed to do; or are we supposed to tippy toe around our patients because we are afraid of making them angry because they aren't getting what THEY THINK they need? I'll do the former. I will not apologize for that one bit. I will not compromise my professional judgement or rationale just to make someone "feel good". If I wanted to do this, everyone would get heat, ultrasound, massage and I would see them for 60 visits for a sprained ankle. It's thinking like this that gives PT's a bad name or at least a diminished public view of what it is we do.

I may sound like a jerk, but this is a battle I've been fighting for 18 months at my job and it is a sensitive subject for me.



jesspt -> RE: In reference to the overtreating thread (March 12, 2008 2:54:43 PM)

ysumpt,

I may be stating the obvious here, but it sounds like you need to consider another place of employment.



orthotherapist -> RE: In reference to the overtreating thread (March 12, 2008 3:01:06 PM)

ysum

125 miles commute, non-clinical boss telling you how to treat patients/breathing down your neck.  Like Jess said look for other employment pronto. 

Your situation makes me me relive my previous job. 

Good luck



ysumpt2006 -> RE: In reference to the overtreating thread (March 13, 2008 7:23:45 AM)

Believe me, I'm looking. Not a lot of jobs in this area unless I want SNF--I don't.

Am I in-line with my thinking? Am I being overzealous?



buckeye -> RE: In reference to the overtreating thread (March 13, 2008 2:29:49 PM)

ysumpt - Are you only looking for PT jobs that are non-SNF in your close area? There are jobs in Ohio - but they may mean moving from your current living area.



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