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Toni Talks about PT Today


Published January 29, 2008 11:04 AM by Toni Patt

I'm a big fan of talk radio.  So when the topic is healthcare related my ears perk up.  On a recent show the topics was a discussion about why Medicare is going broke.  One of those reasons was the belief that everyone is entitled to any and all available medical care no matter what cost at all times.   The show went on to explore the costs associated with that.  The host took the position that just because  a treatment is available,  that doesn't mean the treatment should be used.  Rather, he favored a system of limiting treatment to those that were feasible and cost effective. 

I see this to a lesser extent in the world of therapy.  In this case the issue isn't so much cost as utilization of services.  There is a finite amount of therapy a department can provide.  When demand for services exceeds that care suffers.  The first line of defense is usually shortening treatments so that everyone gets a little something.  The positive side is that more patients on case load receive therapy.  The down is twofold.  First, some therapy isn't necessarily the best therapy.   Doing exercises with someone just so that someone can be said to have therapy isn't enough.  Same for edge of bed exercises when the patient really needs to get into a chair but can't because of time restraints.  

The second downside is more insidious.   There are therapists who can't think outside the box.  Its almost like they memorized for this diagnosis you do that treatment.  I don't' think this is the best approach but it can be effective.  The problem is when you take those therapists  and tell them to do something different, for example see more patients by spending less time with each.   I worked with someone like this.  He couldn't do it.  If anything fewer patients were actually seen because he wasted so much time explaining why he couldn't make those changes.  

These aren't the problem.  They are symptoms.    The problem is therapy is being ordered for patients who aren't appropriate.  The do  everything available mentality has trickled down.  Just because therapy is offered doesn't mean it is appropriate.  I'm saying we should deny therapy.  In theory everyone deserves that chance.   If an order is written, a therapist responds.  An evaluation is completed.  Most facilities will follow patients on a trial basis.  The problem is the stress these trial patients put on an already over worked staff.   There is an assumption that if an order is written the patient will receive therapy when in reality all the order does is initiate an evaluation.  We go to school to learn how to be therapists.  We learn how to use clinical reasoning.  If my clinical reasoning is good enough to develop treatment plans based on an evaluation it is also good enough to recognize someone won't benefit from therapy. 

It's a shame we're not allowed to do that.  I've tried.  First of all let me say dependent isn't a bad word.  It's a description of functional status.   The same is true of being at baseline. If a person's status is the same after admission as before admission they are at baseline.  The goal of therapy is to recover function.  Baseline implies maximum functional level.  That does not indicate therapy.  A decline in functional status indicates therapy.  This may seem obvious to you and I.  It isn't to everyone else.  Admission to a hospital isn't an automatic referral to therapy.  If a patient doesn't want therapy I'm not accomplishing anything going back the next three or four days to be sure.

In case it isn't obvious, this is one of my pet peeves.   Anyone that needs therapy should receive it.  Anyone referred to therapy should be given a chance.    The radio talk show host I mentioned earlier summed up the situation by saying over utilization is draining healthcare.  The same is true of therapy.  By relying on our clinical judgment all those who will benefit from therapy will receive it.  Those who won't will come off case load.  Controlling case load will result in better treatment because no one will be as rushed.  

posted by Toni Patt


I have had discussions with many people and it begins like this, "I want to do therapy and I have a right to be here 100 days"

I say to the patient, "What if you get better in 15 days, do you still want to stay here (in the nursing home) for 85 more days?"

On the flip side of this, if I, as a consumer want a service that my insurance has for me, shouldn't I be able to access that service?  And because one of us says it is not necessary there are others that will accept the patient.  

In acute care, where I began my career, there were evaluations done and treatments completed on patients that I questioned alot.  But to justify it the patients were in the hospital for 2-5 days and if we did not get them out of their rooms no one else did.  

In a SNF I see dead people.  Not literally but some of them should not be up out of bed because they are medically unstable, yet an eval is completed with a POC, goals (both long term and short term) and I am expected to follow this.  

So, naturally, I question the PT and then the patient is seen by another therapist.  Great, I showed them who should be on therapy.

When caseloads are high great more work, overtime, security of the job etc.  When the census is low, guess who has to go home early because my productivity is at stake.  

Don't get me started on my productivity.

Jason, PTA February 10, 2008 1:48 AM

Ah, the great debate.  Patient goes to the doctor, says they want to go to therapy (for something) and, voila, they get the prescription and off they go.  Do the evaluation, determine that, having to use your arms to push up off an arm chair is NOT a loss of function and suggest that the patient do a home program of exercises.  Done?  Nah.  You get the, "My doctor gave me a prescription for therapy and by golly that is what I am gonna get!"  This is the dawning of the age of entitlement, to steal from the 5th Dimension song of the 70s.  If it is there, and I want it, I should have it.  The government says so.  Yes, the government gives us the free cheese, etc.  Have you ever had a discussion about the rules that Medicare has set down regarding "significant improvement in a reasonable period of time" or the appropriateness of a referral for "skilled care by a licensed PT" with an octogenarian?  They paid into Medicare and now they want what they paid for.  It has been years since I was in acute care, like 22 of them.  Even then the referrals were strange but they were meant to do only one thing, and if you think it was to improve someones function, well, there is a bridge in Brooklyn I am trying to sell.  It is all about billing.  How about a paraplegic sent to PT for ambulation training.  How about gait training for an amputee, FULL WEIGHTBEARING, no prosthetic by the way.  

I have many Medicare patients who like coming to PT, someone to talk to, who cares about them, who will listen to them.  Don't get me wrong, I love all my patients, but we all have rules to work by.  Anyway, I don't know what the answer is but with Medicare in the shape it is in, do we really want them to run the entire health care system in this country?  They have not met a program that they could not run into the ground and bankrupt.  When they say it costs 20million, they mean 60 million.  So, taxes go up, and as health care providers, the reimbursement goes down.  On the plus side, I guess they won't get as much tax money from me.  Jokes on them I guess.

Carl, Physical Therapy - Owner February 7, 2008 2:54 PM
Fredericksburg VA

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