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Efficient and Effective Care

“Proliferation of these staffing models (increasing the use of PTA’s and aides) has been driven by managed care organizations, the introduction of prospective payment systems, and low reimbursement rates, as well as workforce shortages in allied health.”

For those that are unfamiliar with physical therapy and what the titles mean lets do a quick refresher:

PTA = licensed physical therapist assistant (high school + 2 years)

PT = licensed physical therapist (Bachelor’s or Bachelor’s + years)

aide = no required degree with on the job training (no degree needed)

MPT = Master of physical therapy degree (Bachelor’s plus 27 months)

DPT = Doctor of physical therapy degree (Bachelor’s plus 33 months)

Based on the above, one can see that the aide would be paid less than the PTA.  The PTA would get paid less than the PT based on education level alone and all other things are equal.

When insurance companies cut pay to professionals, companies have to decrease their costs in order to continue to make margin.  One way to cut costs is to have fewer PT’s and more PTA’s or aides.  The ethics/legalities of the decision are for a different day.

Some insurance companies are refusing to pay for services provided by PTA’s.

The reason that I bothered to look at this research was a large discussion that took place on a professional FB page in which PTA’s were arguing that the care shouldn’t change from PTA to PT, seeing as PTA’s can perform most treatments that a PT can perform.

I decided to look into this to see if there was a difference and I was shocked by what I found, based on my own experience working in a hospital system.  On the same note, I wasn’t shocked based on some of the reports that I hear from patients and others in the profession.

“Use of support personnel in outpatient therapy settings can double the number of patient visits a therapist can manage per day, thus increasing clinical productivity.”

If I am a PT making $50/hour (using round numbers to keep it simple) and in a typical day I could treat 10 patients with an average reimbursement rate of $95 (please go watch all the videos from Dr. Ben Fung ), then I would cost the company $400 dollars, but make the company $950 dollars.  A gross profit, with the removal of only the PT salary, of $550 dollars per day.

Now, if we have that same PT making $50/hour and a PTA making $30/hour (again round numbers to keep it simple), with each therapist seeing 10 patients per day, then the following numbers are the result.  The salaries would cost $640, but the therapists would generate $1900/day.  A gross profit, with salaries of the therapists removed, of $1260/day.

As you can see, the company would be able to generate more money by hiring PTA’s instead of a second PT.  The question then becomes is it cost effective to have the PTA compared to the second PT.  The answer at a glance is “of course”!, but looking a little deeper may force a company to weigh values (i.e. profit or outcomes) before making that second hire.

“While some advocate use of support personnel to increase productivity without loss of quality, others warn that an over reliance on support personnel can negatively affect outcomes and compromise quality.”

This is essentially the discussion that occurred on FB.  Some people say that PTA’s provide the same quality of care as PT’s and others state that PTA’s offer less quality care than PT’s.

I’ve worked with rockstar PTA’s (plus my wife is a PTA so I am already a little biased) and I’ve worked with some PT’s that I would never refer a patient to (no offense if you think that this is you).

“Three dependent variables were analyzed: high PTA utilization, number of visits per treatment episode, and patients FHS (functional health status) at discharge…high PTA utilization, defined as a patient seen by a PTA 50 percent or more of the treatment time”

High PTA utilization, in this study, meant that the PTA was seen by the PTA for over 50% of the visits.

Again, I have worked in locations in which this was true and locations in which we had no PTA’s, so I have seen the results from both.

Looking at treatments per episode is a means of measuring efficiency of treatment.  It may not be the best measurement, but is one way of looking at treatment efficiency.

Looking at outcomes is one way of looking at effectiveness of treatment.  Again, it may not be the best way, but it is one way.

“…less than 2 percent of patients were treated by the PTA for more than 75% of the treatment time, and 8 percent were treated by the PTA 50% of the time or more.”

I’ve been in clinics without PTA’s and with PTA’s.  This stat will be correlated with the amount of PT’s/PTA’s in the clinic.

In private practice, it was 0 PTA’s.  In the hospital we had 1.5 PTA’s for 4 PT’s.  Currently, in my practice there are 2 PTA’s for 1.5 PT’s.

“The second dependent variable, number of visits per treatment episode…We believed that fewer visits per treatment episode were a marker of greater efficiency of care”

This is debatable by people.  I’ve actually been involved in these on-line debates.  Some people will fight that more visits equals better, but more is not always better.

If we can get patients better in shorter visits, then this seems to be ideal to me.  If additional visits would correlate with increased function, then I would be all for increased visits if the patient is willing and able to pay for increased visits (time and money).

“The majority of physical therapy care was delivered by PTs with no reported assistance from PTAs.”

Again, in a clinic without PTA’s, there will be no reported assistance from PTA’s.  This study used data from FOTO, which included private practices and hospital based practices.

“PTAs were involved in the care of patients only 35% of the time. High PTA utilization was relatively uncommon, with only 7.7 percent of the patients seen by PTAs more than 50% of the time.”

This is interesting.  It is becoming more and more common to find clinics advertising/marketing that the patient will only be seen by a PT, or even a step further a Doctor of Physical Therapy.  I don’t know how well this marketing is going.

When seeing it, it subconsciously implies that a DPT is better than a PTA.  I think that this is very individualized.  For example, a PTA that has continued to improve over the years through independent study may be a better clinician than a PT that never sees patients (administration/teacher/manager).

“Medicare patients who were seen in private practice were 48 percent less likely to have had high PTA utilization.”

Some insurance companies require that a patient be seen by a PT and prohibit PTA’s from treating patients.  This will skew numbers towards the PT in private practice.

“Treatment with a therapy aide for 1-25 percent time and greater than 25 percent compared with 0 percent, and high utilization of the PTA were associated with 1.8, 2.6 and 2.0 more visits, respectively.”

Lets break this down.

Being treated by a therapy aide for 1-25% of the time resulted in 1.8 more patient visits per episode.

Being treated by a therapy aide for > 25% of the time resulted in 2.6 more visits per episode.

Being treated by a PTA for greater than 50% of the time resulted in 2.0 more visits.

Remember, an aide is someone that may not have any college experience or degrees.  The aide is not legally able to treat patients that are payed by the government.

Utilizing an aide only results in slightly more visits than using a PTA! Why is this?!

An aide is paid much less on average than a PTA.  For example, the aide may only cost the employer $12.50/hour.  The PTA will cost the employer $30.00/hour.

I see employers trying to cut costs by hiring more aides (not ethical to call it physical therapy if it is not provided by a licensed physical therapy professional IMO).

If it doesn’t change the outcomes though, who’s to argue against it?

I can see both sides of the coin.  Margins (profits) in physical therapy is small, so cutting costs is a business decision.

Providing quality care is something that IMO we should all strive for.

“Greater than 50% time spent with the PTA was predictive of lower discharge scores as was time spent with a therapy aide.”

This part may be the most important statistic in the article.  Seeing someone other than the PT led to worse outcomes.

This is the statistic that I was looking for because of the original question asked.

In other words, the PT will get a patient better than a non-PT and do it faster in an outpatient setting.

Strong words for businesses and people looking to go to PT school.

What is the future of PTA’s?  I don’t know.  Medicare just announced that they will be reducing reimbursement rates for PTA’s in an outpatient setting.  Pair this with the small margins in physical therapy and the question becomes is it profitable to hire PTA’s in an outpatient setting, seeing patients according to Medicare rules?

“…our analysis shows that Medicare regulations for continuous in-room supervision of PTA’s in private practice are associated with a decreased likelihood of high PTA utilization.”

 

“High utilization of PTA’s, and use of therapy aides were each independently associated with more visits per treatment episode, and lower functional health. Thus our findings suggest that use of care extenders such as PTA’s and therapy aides in place of PT’s is associated with more costly and lower quality care delivery in outpatient rehabilitation.”

 

I advise all people to look to the source:

link to article

 

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Categories: Physical therapy, PTs, Written BlogsTags: , ,

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