RE: Fw: PT 'Thought Leaders'

[Guest guest]

Several years ago MD's in Sioux City, IA stood up to what they perceived to

be a poor contract with Wellmark/BCBS of Iowa. As a group of MD's backed by

the local hospital(s), they refused to sign a new agreement and opted out of the

par provider network. An interesting thing happened. They called a press

conference to disclose their reasons for backing out. The local media covered

it and immediately it hit the front pages of most of the newspapers across the

state (except for the Inquirer, which was running a story about a young boy

raised in the sewers by raccoons...aah, but I digress). Anyway, Wellmark sent

representatives over to meet with the MD's and within a week had an agreement

that was mutually suitable.

I wonder what would happen if all PT's, OT's and SP's joined their local and

national chapters. Then, in attending meetings, the local chapters would

identify the worst contracts being dictated by insurers. This information would

be reported up to the national associations and a target list would be

developed. At a certain point in time, the national association would tell all

therapists to begin cancelling contracts. A letter would be sent to the insurer

by

the national chapter prior to the start of contract cancellations to let them

know how things are going to happen and why. I suspect that people at our

national chapters would have to request help from individuals to make the noise

required. There would also have to be buy-in by hospital PT's, Rehab Agencies

and PTIPP's in order for this to work. Call in the press at the same time. I

won't go any further, I think you get the picture.

Okay, off my soapbox,

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

[Guest guest]

Physical Therapists are welcome to join Physicians for National Health

Care. I am a member, but sadly am not attending their conference this

weekend.

Striffler, PT

Ithaca, NY

Beth Rohrer wrote:

> Some of the comments in this email (thanks, Dave – interesting comments) and

the UnitedHealth email sent recently by Mark have prompted me to throw out some

additional thoughts.

> <?xml:namespace prefix = o ns = " urn:schemas-microsoft-com:office:office " />

> The majority of the frustration I have heard coming across the list serve the

last several years is due to our profession having to react to some outside

force, whether it be legislation, health insurance reimbursement, or territorial

squabbles with other professions. We seem to do a fair amount of screaming from

within our little PT circle, hoping someone listens, but I propose that that a

more effective way to create change is to step outside of the PT huddle and to

be a player in setting the course for the rapidly changing world of healthcare.

>

> Last week I attended the World Health Care Congress 2006, which included what

was advertised as the ‘top thought leaders’ in health care. It was a forum

where the emerging ideas in health care were discussed….but I saw no PT

representation. I did see Dr. McGuire (CEO of UnitedHealth), Ed Hanway

(CEO of CIGNA), Mark McClellan (CMS), etc., however, so I can’t help but wonder

what our future will be like if the circle of people considered the ‘top thought

leaders’ consists of all non-PT players.

>

> I propose that unless there is a segment of our profession that focuses on

embracing the rapid changes occurring in healthcare, taking advantage of

multiple opportunities to be a major player in solving the health care crisis,

and taking a seat at the table where a lot of the critical decisions are being

made, we will continue to be frustrated as we are forced to react to what others

dictate.

>

> Here are some of the questions going through my head:

> What ideas has our profession proposed and implemented for helping to solve

the problem of spiraling health care costs? I propose that tackling issues such

as this could go far in increasing our profession’s respect from both the

‘thought leaders’ and the consumers in the current health care environment.

> What is our profession doing proactively to support making cost/quality data

available to consumers, a critical component in the consumer-driven healthcare

world?

> What is our profession doing to be a frontrunner in prevention/lifestyle

programs that are being integrated into many insurance policies?

> >From an information technology perspective, the health care industry is

pitifully behind compared to both other industries and to health care systems in

other countries. We’re making a lot of strides in this area….electronic medical

records (EMR), personal health records (PHR), Regional Health Information

Organizations (RHIO), national provider ids (NPI), etc. Is anyone from our

profession ‘at the table’ in these important initiatives? Or will we be forced,

again, to react to what has been designed without our input?

> Beth Rohrer, PT, DPT

> Centreville PT

>

>

>

> RE: Some thoughts on ACN and Corporate PT

>

> Beth,

>

> This is in answer to your request regarding HSAs. (Sorry for the lateness,

> but it's budget time around here...)

>

> I'll try to respond to both you and Mark Schwall, since you both expressed

> concern about how HSAs might develop (specifically, how they could become

> just another version of our current mess).

>

> To both of you, I say, you are right! Any good idea can be destroyed by

> dilution, or modification, or restriction, or whatever, and there are more

> than enough rascals in government and business ready and willing to do just

> that. But to abandon a good idea because some nefarious characters might

> foul it up is crazy. The fact that you have both identified negative

> potentials shows that we can keep our eyes open wide enough and long enough

> to make sure that nobody messes with this potentially very good thing. Beth,

> you are right that HSAs haven't even gotten off the ground and are already

> restricted to the point of unrecognizability. But again, it is sadly

> fatalistic to give up because of that.

>

> Even though government has shown a dogged desire to foul this up, I will

> nevertheless suggest that government does in fact have a role in the

> development of HSAs. My favorite plan is to have Uncle Sam fund an

> unrestricted HSA for every American citizen, and out of those individual

> accounts each person would individually pay for as much of his healthcare

> costs as determined to be reasonable, including the cost of a catastrophic

> plan. It would not be unreasonable to give every US citizen---man, woman,

> and child, a $20,000.00 HSA, and let them spend it as they wish to maintain

> their own health. Any dollars earned through investment over the 20K should

> be that individual's to keep and spend as he wishes. (If you can stay

> healthy enough to make money on your HSA, more power to you!) The trigger

> for the catastrophic plan should be that more than a certain percentage of

> the HSA principal was spent. That is simply fairness put into practice. You

> would be responsible for your own health, and if you do get sick or injured,

> protected from financial collapse (by a policy that YOU shopped for). Now

> some people have expressed concern that people will skimp on prevention, or

> spend their money unwisely on quack services. I will certainly not deny that

> possibility. There will be those who sacrifice a chicken to cure their back

> pain. But we must remember that it is THEIR back pain. As long as I do not

> suffer for your lack of wisdom, I have no problem with your HSA buying a

> chicken. It seems to me that HSAs would naturally incentivize the pursuit of

> health. (I might also point out, as we consider fairness, that catastrophic

> plans would, if left to market forces, naturally be more expensive for

> smokers, NASCAR drivers, and rodeo riders, as well they should be. I see

> only positives in the monetary incentives to maintain health and safety.)

>

> Now I will take a gentle swipe at all of us. This endless complaining about

> how one provider group (read: special interest) or another has " stolen " more

> of the third party pie than they presumably deserve (and PTs do more than

> their share of whining) is, to me, a clear indicator in the differential

> diagnosis of ROTTEN SYSTEM. Does anyone really believe that the infighting

> will end while the customer is not allowed into the discussion?! The ONLY

> fair arbiter of service value is the patient. Until all providers must prove

> their worth at the point of service to the CUSTOMER (read: patient) we can

> expect the battling and the whining and the politicking and the sheer

> roguishness to continue.

>

> All men are frauds. The only difference between them is that some admit it.

> I myself deny it. H. L. Mencken

>

> Dave Milano, PT, Director of Rehab Services

> Laurel Health System

> 32-36 Central Ave.

> Wellsboro, PA 16901

>

> dmilano@...

>

>

>

>

>

>

>

[Guest guest]

Jim,

I recall the incident. Could not agree more that we as a profession need to

take a new approach if we are going to remain viable. As a first step I

would challenge those chapters preparing for the upcoming House of Delegates to

take a real leadership role and address the issues of reimbursement, POPTS,

CPT coding, time documentation and the restriction it imposes and places

arbiter treatment limitations, i.e. 15 minute rule with its 32 unit rules in a

eight hour day. Just for starters. How about seeking legislation restoring

the

old Stark rules?

My .2 cents

[Guest guest]

Joe

You are correct in assuming that you might encounter legal problems if all of

the members of APTA dictated pricing. This isn't about dictating the

price-it is about people standing up and saying-we cannot work at prices that

are

below the cost of services. No where in my note did it mention price fixing,

gouging or a set fee. My note said that the organization should target

companies

that have poor reimbursement and immediately take action as a whole to cancel

contracts with that company.

Also, using your context, all of the Doctors and Hospital Administrators in

Souix City, Ia would be in jail for rejecting something they didn't like. I

don't recall any Department of Justice inquiry into the matter after it was

concluded.

One last comment. Yesterday, someone in NJ sent me a private post indicating

SIG in that state shot this idea down at one point. That doesn't mean that

the idea doesn't have merit, it means that at that point in time it wasn't

right for the leadership group of that state. Maybe the leadership dynamics

have

changed since then. Maybe the economic positions of the leader's

organizations have changed since then. Depending on how the situation is

handled with the

media, some people might be opposed. For example, I wouldn't want someone in

front of a camera screaming that an insurance company was treating everyone

unfairly. However, I would love to see someone step in front of a camera

saying something to the effect that, " as a group, we the members of FILL IN THE

ORGANIZATION have decided to cancel our contract with insurance company XYZ. We

have taken careful consideration to the terms of their contract. Their terms

are dictated to us and we have no say in the terms. We have studied the

pricing they have provided to us individually and collectively and we cannot

cover

our costs and continue in business. At this time we have chosen to not renew

our contracts. Any patients that have this insurance is still welcome to

come to our clinic(s) for treatment. However, they will be responsible for

paying for our services at the time of treatment.

While I do not have all of the answers, there are literally thousands of

Therapists that know their situations and have to live with them every day.

These

are the individuals that need to cry out for help. I know of VERY FEW

insurance companies that negotiate contracts with Therapy Providers. They hand

a

contract that is one sided and tell the provider to take it or leave it. Many

therapists take it because Doctors in there area do not want to think through

which networks the providers are in or out of. If all therapists opt out of a

network and everyone is made aware of it, then it shouldn't be a referral

issue.

Okay, off my soapbox and on to Sunday Services,

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

[Guest guest]

Interesting ideas Jim. Do you think our local and national chapters

would also be willing to bail us out of jail?

Please see http://www.usdoj.gov/atr/public/speeches/0106.htm for an

interesting presentation on antitrust and trade associations.

Joe Libera

Burlington, NC

>

> Several years ago MD's in Sioux City, IA stood up to what they

perceived to

> be a poor contract with Wellmark/BCBS of Iowa. As a group of MD's

backed by

> the local hospital(s), they refused to sign a new agreement and

opted out of the

> par provider network. An interesting thing happened. They called a

press

> conference to disclose their reasons for backing out. The local

media covered

> it and immediately it hit the front pages of most of the newspapers

across the

> state (except for the Inquirer, which was running a story about a

young boy

> raised in the sewers by raccoons...aah, but I digress). Anyway,

Wellmark sent

> representatives over to meet with the MD's and within a week had an

agreement

> that was mutually suitable.

>

> I wonder what would happen if all PT's, OT's and SP's joined their

local and

> national chapters. Then, in attending meetings, the local chapters

would

> identify the worst contracts being dictated by insurers. This

information would

> be reported up to the national associations and a target list would be

> developed. At a certain point in time, the national association

would tell all

> therapists to begin cancelling contracts. A letter would be sent to

the insurer by

> the national chapter prior to the start of contract cancellations to

let them

> know how things are going to happen and why. I suspect that people

at our

> national chapters would have to request help from individuals to

make the noise

> required. There would also have to be buy-in by hospital PT's,

Rehab Agencies

> and PTIPP's in order for this to work. Call in the press at the

same time. I

> won't go any further, I think you get the picture.

>

> Okay, off my soapbox,

> Jim Hall, CPA <///><

> General Manager

> Rehab Management Services, LLC

> Cedar Rapids, IA

> 319/892-0142

>

>

>

[Guest guest]

:

I have the utmost respect for you, and am generally in agreement with what

you say, but I must disagree with you here. I don't think that we should be

arguing that we should be paid for more services than we are actually

providing, but that these services should be more valued. We must

understand, however, that we will not increase value for the purchaser, by

simply decreasing what is delivered.

First and foremost, we need to actually have control over these services,

which we do not now. Moreover, we need to have some uniformity in how these

services are being delivered and represented, which we also do no not have

now. Unless and until the physical therapy profession gains complete

control, and ownership, of physical therapy services we will have limited

impact in determining the future of our own profession.

This is ALL about ownership, and despite how this argument is being

misunderstood (misrepresented?): Ownership is NOT integral to Autonomy, it

is integral to Control.

Ken Mailly, PT

Mailly & Inglett Consulting, LLC

www.njptaid.biz

Delegate to APTA HOD

> Re: Fw: PT 'Thought Leaders'

>

> Jim,

>

> I recall the incident. Could not agree more that we as a profession need

to

> take a new approach if we are going to remain viable. As a first step I

> would challenge those chapters preparing for the upcoming House of

Delegates to

> take a real leadership role and address the issues of reimbursement,

POPTS,

> CPT coding, time documentation and the restriction it imposes and places

> arbiter treatment limitations, i.e. 15 minute rule with its 32 unit rules

in a

> eight hour day. Just for starters. How about seeking legislation

restoring the

> old Stark rules?

>

> My .2 cents

>

>

>

>

>

[Guest guest]

Ken,

Could not agree more that we need to gain control of our profession. That

was my point. We have been dictated to by Federal and State governments.

Third party payers own the show and we are bit players in the whole production.

Once again we are being told that PT is too expensive and over utilized. It

will be sung by CMS again this year. But, when queried, as I did last year,

they do NOT have specifics. How long have we tried to sell the argument

that if it isn't done by a PT or under our supervision than it isn't PT. That

speaks to your concern that we need the onus of responsibility for our

profession. Unfortunately I see that fading away as more of our talent seems

to

lean toward the association with referral sources and the big buck. On the

other hand, there is a lot of bad stuff out there and it is called PT. I would

venture to say that as the proliferation of " practices " grow there will be

good reason to question the value and efficacy of much of that treatment. We

are having a lot of concern with the quality of home health that our patients

are experiencing. Much to our surprise, some of the Doc's are bypassing that

step and sending the patient in as an outpatient. It is always rewarding to

see quality appreciated.

I think we both have dedicated too much effort to not want this profession

to grow and prosper in such a way that those we serve so well still have that

opportunity. I would welcome a new infusion of enthusiasm from a much

broader base of colleagues.

I will now shut up. Have a great day, see you in Orlando.

Pete

[Guest guest]

Thank you for acknowledging the problem Jim.

My understading is that no PT agency is compelled to sign a contract

with a third party payer. Using a trade association to " target

companies that have poor reimbursement and immediately take action as

a whole " appears anticompetitive and may imply collusion.

The NJ SIG shot down the idea with good reason Jim. Assuming the NJ

SIG continues to benefit from thoughtful leadership, they will

continue to view the idea as dangerous for the profession and for

individual PTs and PT practices. Independent PTs and agencies should

act independently in order to serve the medical and economic good of

all consumers. Any movement by competitors to band together to set a

base price may be seen as an agreement to fix prices. It implies

sharing costs with competitors (including price sharing). Your

suggestions also seems to imply a boycott of certain payers or similar

unfair practices.

Joe Libera

>

> Joe

>

> You are correct in assuming that you might encounter legal problems

if all of

> the members of APTA dictated pricing. This isn't about dictating the

> price-it is about people standing up and saying-we cannot work at

prices that are

> below the cost of services. No where in my note did it mention

price fixing,

> gouging or a set fee. My note said that the organization should

target companies

> that have poor reimbursement and immediately take action as a whole

to cancel

> contracts with that company.

>

> Also, using your context, all of the Doctors and Hospital

Administrators in

> Souix City, Ia would be in jail for rejecting something they didn't

like. I

> don't recall any Department of Justice inquiry into the matter after

it was

> concluded.

>

> One last comment. Yesterday, someone in NJ sent me a private post

indicating

> SIG in that state shot this idea down at one point. That doesn't

mean that

> the idea doesn't have merit, it means that at that point in time it

wasn't

> right for the leadership group of that state. Maybe the leadership

dynamics have

> changed since then. Maybe the economic positions of the leader's

> organizations have changed since then. Depending on how the

situation is handled with the

> media, some people might be opposed. For example, I wouldn't want

someone in

> front of a camera screaming that an insurance company was treating

everyone

> unfairly. However, I would love to see someone step in front of a

camera

> saying something to the effect that, " as a group, we the members of

FILL IN THE

> ORGANIZATION have decided to cancel our contract with insurance

company XYZ. We

> have taken careful consideration to the terms of their contract.

Their terms

> are dictated to us and we have no say in the terms. We have studied

the

> pricing they have provided to us individually and collectively and

we cannot cover

> our costs and continue in business. At this time we have chosen to

not renew

> our contracts. Any patients that have this insurance is still

welcome to

> come to our clinic(s) for treatment. However, they will be

responsible for

> paying for our services at the time of treatment.

>

> While I do not have all of the answers, there are literally

thousands of

> Therapists that know their situations and have to live with them

every day. These

> are the individuals that need to cry out for help. I know of VERY FEW

> insurance companies that negotiate contracts with Therapy Providers.

They hand a

> contract that is one sided and tell the provider to take it or leave

it. Many

> therapists take it because Doctors in there area do not want to

think through

> which networks the providers are in or out of. If all therapists

opt out of a

> network and everyone is made aware of it, then it shouldn't be a

referral

> issue.

>

> Okay, off my soapbox and on to Sunday Services,

>

> Jim Hall, CPA <///><

> General Manager

> Rehab Management Services, LLC

> Cedar Rapids, IA

> 319/892-0142

>

>

>

[Guest guest]

Joe;

I think theoretically you have a point. Practicality is another issue.

Let's look at Labor laws and I will paint with a broad brush here. Employees

started gathering together to protest wages in the late 1800's early 1900's.

After people got together and fought (in this case some physical battles), the

nation stood up and took notice. Eventually the laws changed to start

protecting

those individuals and unions were born (please do not misunderstand me-I am

not in favor of unions, but I do believe they can serve a useful purpose).

Today, employees can talk freely and share information within an office about

what they make, when their last raise occured and other things that I-as an

employer, might find objectionable. Guess what, there's not a darn thing I can

do

about it.

Okay, going back to my original comment (which I think is being taken out of

context). If private practitioners talk about their reimbursement and the

worst payers, groups can figure out which insurance companies are offering the

worst contracts. On the scale you are talking about, how many PT's are in your

state. In order for DOJ to intercede, you will have to have extremely high

numbers and dictate the terms of contracts for not one but a bunch of contracts.

At no point have I suggested that you work together on terms of a contract.

What I have suggested is that everyone (that is interested) opt out of a bad

insurance contract at the same time and step forward explaining to the media

why they are doing so.

Now, you have expressed concern about issues like monopoly and collusion.

Let's flip sides of the fence. BCBS in the state you reside in will have

approximately 50% of the covered lives under an insurance contract. Each and

every

provider gets exactly the same terms. The fee schedules are the same. Gee,

sounds like it is price fixing. Is there any inquiries going on at the state

level to prosecute this? Also, the insurance industry is slowing shrinking as

major players like United Healthcare purchase other companies. Again, this

could be viewed as restraint of trade and prosecuted. I haven't read any front

page stories about feds looking into Sherman Anti Trust Acts.

My point is that you and I could debate this issue for several more emails

and my guess is that I would have to respectfully agree to disagree with you on

this topic. More importantly, it would be better to have an attorney weigh in

on this topic.

Thanks for shaking it up a bit Joe!

Jim Hall, CPA <///><

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

[Guest guest]

In light of this exchange, consider the following:

WASHINGTON, April 29 - Federal investigators have found that a handful of

companies account for a growing share of the health insurance policies sold

to small businesses in most states, leaving consumers with fewer options and

higher costs.

http://www.nytimes.com/2006/04/30/us/30insure.html

Ken Mailly, PT

Mailly & Inglett Consulting, LLC

www.NJPTAid.biz

> Re: Fw: PT 'Thought Leaders'

>

> Joe;

>

> I think theoretically you have a point. Practicality is another issue.

> Let's look at Labor laws and I will paint with a broad brush here.

Employees

> started gathering together to protest wages in the late 1800's early

1900's.

> After people got together and fought (in this case some physical battles),

the

> nation stood up and took notice. Eventually the laws changed to start

protecting

> those individuals and unions were born (please do not misunderstand me-I

am

> not in favor of unions, but I do believe they can serve a useful purpose).

> Today, employees can talk freely and share information within an office

about

> what they make, when their last raise occured and other things that I-as

an

> employer, might find objectionable. Guess what, there's not a darn thing

I can do

> about it.

>

> Okay, going back to my original comment (which I think is being taken out

of

> context). If private practitioners talk about their reimbursement and the

> worst payers, groups can figure out which insurance companies are offering

the

> worst contracts. On the scale you are talking about, how many PT's are in

your

> state. In order for DOJ to intercede, you will have to have extremely

high

> numbers and dictate the terms of contracts for not one but a bunch of

contracts.

> At no point have I suggested that you work together on terms of a

contract.

> What I have suggested is that everyone (that is interested) opt out of a

bad

> insurance contract at the same time and step forward explaining to the

media

> why they are doing so.

>

> Now, you have expressed concern about issues like monopoly and collusion.

> Let's flip sides of the fence. BCBS in the state you reside in will have

> approximately 50% of the covered lives under an insurance contract. Each

and

> every

> provider gets exactly the same terms. The fee schedules are the same.

Gee,

> sounds like it is price fixing. Is there any inquiries going on at the

state

> level to prosecute this? Also, the insurance industry is slowing

shrinking as

> major players like United Healthcare purchase other companies. Again,

this

> could be viewed as restraint of trade and prosecuted. I haven't read any

front

> page stories about feds looking into Sherman Anti Trust Acts.

>

> My point is that you and I could debate this issue for several more emails

> and my guess is that I would have to respectfully agree to disagree with

you on

> this topic. More importantly, it would be better to have an attorney

weigh in

> on this topic.

>

> Thanks for shaking it up a bit Joe!

>

> Jim Hall, CPA <///><

> Rehab Management Services, LLC

> Cedar Rapids, IA

> 319/892-0142

>

>

>