Friday, December 14, 2012

Important information about why your OT is eyebrow deep in paperwork

How would you like to wake up one morning and find out that there are new rules you need to know in order to get your paycheck at the end of the week?  Those of us who work in private practice understand that the rules for reimbursement change and shift constantly, but imagine wading through hundreds of pages in the hopes of trying to find the tidbits that actually apply to what you are supposed to be doing.  Enjoy this link for some light reading: Medicare Physician Fee Schedule Final Rule CY 2013 .  These requirements were just recently published and significantly change the coding requirements for Medicare reimbursement.  Again.

Other changes that we have this week are more wonderful rules to contend with - this time having to do with complex requirements for what a physician's referral has to say in order for a school district to bill related services under the Medicaid program.  This NYS Medicaid rule set is not as long as the CMS rules but only covers a very small component of service (what MD scripts have to say) - but it is just as confusing.  I like to think that I am at the least a moderately well educated person and in addition to my doctoral education I also have some measure of common sense - so why is it so challenging to wade through and try to understand these arbitrary rules?  Here are the new NYS Medicaid requirements for scripts.

As you can see in the new Medicaid rules they initially tolerated certain language in scripts, then they expressly prohibited that language, and now they are back to accepting that language again (I think).  These are small issues, actually, and have to do with whether or not a physician can write 'PER THE IEP' on a script or whether or not frequency, duration, and other factors need to be separately noted.

What is most frustrating is that with every rule change comes the accompanying threat (generally not even covert) that if you fail to follow the rules that you are committing Medicaid fraud.  The friendly State reminds us in the memo:

18 NYCRR 515.2(b)(1)(c), Unacceptable practices under the medical assistance program, states that an unacceptable practice is conduct which constitutes fraud or abuse and includes submitting, or causing to be submitted, a claim or claims for medical care, services or supplies provided at a frequency or in an amount not medically necessary.

Now no one who is trying to figure out the new rules is purposely trying to commit fraud - but here is a case where there are two conflicting demands.  Medicaid will not pay for a service that is beyond what is written on the script, but at the same time the State Education Department demands that all missed services be 'made up.'  In fact, parents are legally entitled to compensatory services when absences or other events prevent a child from receiving the services on any given day.  So, 'making up' services might cause you to try to see a child in a way that is not listed on the script because it might not be realistic to make up those services within the same week that they were missed.  BOOM!  Medicaid fraud - because as it stands now the reporting forms that we use to track service delivery are not separated and if the district attempts to bill for something that is different than the physician's script then you are now considered guilty of Medicaid fraud.  It is truly a rock and a hard place.

The reason why this matters is because none of it has anything to do with the care that children receive - at least not in any direct sense.  The rules are arbitrary, and they change, and they distract care providers from the important tasks that they SHOULD be focusing on. 

So-called concierge models of care eliminate insurance companies and return relationships back to a normalized interaction between providers and the people who are seeking services.  The legitimate criticism is that this model creates access barriers for people who do not have enough money to pay for services privately.  Many medical practices are experimenting with hybrid models to address that criticism.  When there are constant rule changes and complexities that create barriers to care these concierge models start to look very appealing, even though they have limitations.

Parents need to be aware of these kind of issues, which although might be superficially boring really do have an impact on the mindset of how care is provided within municipal systems and through complex health insurance rules.  In my opinion there are probably less complex methods for solving these problems, but as we hand more and more control over health care to our government we can expect increasing points of arbitrary decision making, convoluted and conflicting recommendations, and in the end this will all create more barriers to quality care.  As I tell my staff, be prepared for a bumpy ride.

Tuesday, December 11, 2012

Who co-opted my interventions???

This will be a brief entry to serve as placemarker for a larger discussion, if it ends up being warranted.  I have blogged before about my basic understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings.  Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. As Bruner has pointed out, words reflect our beliefs that frame our narratives and support our culture.

Today I was being interviewed by a media person and they were confused about my use of the word 'intervention'  when I was talking about 'occupational therapy interventions.'  This was surprising to me.  My message to them was focused on the friendly context of my clinic and the services we offer, and their understanding of the word 'intervention' was related to a reality television show entitled Intervention.  That was not so good.  The interviewer mentioned that when they think of interventions that they don't think of a friendly process that helps children.  It was one of these moments:

So now I am kind of wondering about my words.  Maybe I need to go back to treatment planning and forget this intervention business.  Has anyone else run into this problem?

Monday, December 10, 2012

The most important part of occupational therapy assessment

This morning my OCC 471 class is taking their final examination as I write this entry.  The class content was focused on occupational therapy assessment in pediatric settings and I am aware that the students are nervous as I sit at the front of the room.  I wish that I had a way to make them feel better.

This blog is generally about my practice and not about my teaching - even though there are many logical points of intersection.  The whole point of teaching is to prepare people FOR practice and I know that all these students spent the weekend trying to answer the same question, "How will I know when I know enough??"

As I was walking toward the college this morning I watched birds flying around the bell tower of Ball Hall.  My immediate thoughts were related to wondering why birds choose the highest spot on campus to congregate.  I figured that there were probably a few possibilities:

  • the like the view of the lake
  • the perch has geographic proximity to nesting
  • their leader went there and others followed
  • high altitude perching is a survival behavior because predators can't get that high
There are probably some reasons that I can't think of.

I am not really sure why the birds were up there, so I decided that maybe they just had lofty aspirations - and I just didn't have enough wisdom to understand their motive.

It is a safe position to take, and it actually leaves open the oppportunity to respect the behavior.  I think that is important.

I mention all this because I wanted to write such a question on the examination but it was hard to put into a multiple choice format.  So while these students learned all about early intervention and school therapy and standardized vs. non-standardized assessments I hope they also learned a little about respecting things where they were - especially when they don't have the wisdom  yet to fully understand a situation.

We run face-first into this as a practice issue every day.  My first encounter with the concept was in a decidedly non-pediatric context.  I was consulting to a nursing home and I was very inexperienced - I often wodered if I knew enough to do a proper job.  Thankfully the COTA was highly competent but more importantly the residents themselves were also highly competent even though they were the ones 'receiving services.'

Of course this pre-dated the current models that drive nursing home reimbursement but at that time occupational therapy served an important maintenance function for those residents.  Many of them had long term and chronic disability but each day the residents made sure that they got to the OT room to do their "work."  Some chose to do craftwork, some participated in cooking groups, some wrote letters (for themselves and others) and some even put pegs into pegboards.  At that time my instincts bristled against that activity choice and I wanted to change their tasks to something that I perceived as being more occupationally and developmentally appropriate.  However, those residents took the initiative to make a sign and they placed it on the door to the OT room.  The sign read something like

Let no one call another man's work insignificant.

That is a really powerful statement, even though my 21 year old mind couldn't really comprehend it at the time.  That was over 25 years ago, and in these intervening years I have taken a deep dive into the source philosophy of Martin Luther regarding Faith and the meaning of Work - and perhaps I am now beginning to understand the aspirations of those residents a little.

They were very wise people.

Anyway this is a recurrent theme when you are gifted with a professional license to provide care.  I believe that we need to be cognizant of the power differentials between caregivers and 'patients' and how we develop understandings of their 'conditions' - like when we do our occupational therapy evaluations!  We also need to be mindful of  how we dispense advice through our interventions.  I think that we might be lucky if we happen to have any wisdom - and even if we do have it then we have to be sure that we don't wield it stupidly.

So do my students know enough???  Do they know if their assessments will lead them to the best interventions???  I just hope that when they see birds flying around bell towers that they will empty their minds of prejudice.  I hope that they will be willing to wait for the wisdom to come to them if they look deeply enough and wait patiently enough for the understanding.

If that happens, I will have served my purpose to them.

Friday, December 07, 2012

Environmental sustainability and occupational therapy practice

I like ideas.  I even like big ideas.  That would include big ideas that are created simply for academic purposes.  However, as my bio indicates, I am a pragmatic guy who is sometimes at odds with his transcendent training.  Or something like that.

So in other words, I thought I liked ideas.  Maybe sometimes I don't.  I am starting to wonder.

The latest barrage of ideas that I got hit with this week has to do with sustainability and its application to occupational therapy.  I have some opinions about this that are probably a logical extension of these ideas that I blogged about in 2009 that relate to developing lexicon related to social or occupational justice constructs.  Please go read that information first if this is a topic that interests you.

OK so this week I saw a student spam posting the OT Connections site trying to get people to answer some survey about the role of occupational therapy with sustainability.  I normally just ignore spam posting but I went to the survey anyway simply out of academic curiosity on the topic - mostly because in my wildest imaginings I could not understand why this would be a legitimate domain of inquiry for an occupational therapist.  The survey was interesting but chock-full of assumptions that I didn't necessarily agree with.  I started answering the questions and then decided to scrap my answers because I didn't have anything constructive to add to the survey, and also because I thought this would be a more effective format for exercising my thoughts on the topic.

For a day or so I just shelved my puzzlement about why someone would think that OT had a role in sustainability but then the barrage of ideas continued.  First there was a message thread passing around the faculty where I teach about the concept of sustainability and how the college should make some movements toward more responsible efforts regarding the environment.  On its surface I don't mind when people promote recycling efforts and turn off lights and consider ways to be more efficient and environmentally mindful but then I started to get a little uncomfortable when there was a call for endowment divestment from big energy companies.  I expressed some concern about conflating methodologies for local sustainability initiatives with methodologies for "sustainability" of an endowment.  I don't know how many academics have had fiduciary responsibility for a large endowment or reserve fund like that so who knows if my cautionary opinions resonate in those halls.  Oh well.

Then a colleague sent me an opinion piece that appeared in the British Journal of Occupational Therapy in September (Whittaker, 2012).  And then someone else sent me a link to the WFOT website and they also have a position paper on environmental sustainability and sustainable practice within occupational therapy.  So there was a barrage of information about this topic this week and I guess I want to talk about it.

I don't want to have a global warming or global cooling or any kind of climate debate.  That would be boring and people are stuck in camps on the issue.  Instead I want to focus on the WFOT call for occupational therapists to "use their expertise and knowledge about occupations and occupational performance to participate in the resolution of these global problems."  According to the WFOT position paper the global problems include human driven global climate change, overuse of finite natural resources, decreasing biodiversity, overpopulation, and inequitable wealth distribution.  That is a pretty big list of problems to address in my little occupational therapy intervention plans here at ABC Therapeutics.  Still, I like to think that I am a cutting-edge kind of guy, so I figured I might have some work in front of me.

I needed some ideas, and since there is no one on the continuing education circuit peddling sustainable occupational therapy I figured I could just read some journal articles.  Whittaker talks about exploring cooking in more sustainable forms by having clients reflect on ecological context and cooking mindfully - which in turn might deepen the meaning of the cooking experience for the client.  His article goes on to explain that livestock farming accounts for 80% of greenhouse gas emissions from all food production.  This got me thinking.  Maybe we are supposed to promote "green" cooking by making peanut butter and jelly sandwiches instead of a ham sandwich during our ADL assessments.  If we stop eating meat and dairy then there will be fewer pigs and cows and chickens expelling their methane into the atmosphere.  I guess.

In the middle of these very deep thoughts I realized that my 8:30am appointment had arrived.  I started thinking that it really wasn't fair of me to even see this family because they have private insurance and are seeking private therapy to address some gross motor delays that their 8 month old daughter is experiencing.  The income inequality allows them to stay away from the municipal early intervention system which is seismically shifting and changing because of constricted funding.  Maybe it isn't fair to see people outside of the municipal system.  Based on these things that I am reading I am now considering the possibility that I am crushing the planet by reinforcing medical consumerism and wasteful spending in an unequal fashion.  Interesting.  Somehow I am not that certain that the parent looks at it all this way.  I wonder if they will mind if I just discharge them and tell them to call for County services?

After the appointment was over I decided to pick up my phone messages.  I thought I was saving some money by managing my own messages and cutting down on support staff but now I am thinking that I should reconsider my profit motive in the interest of more equitable wealth distribution on the planet.  Anyway, there was a message from a mom who was crying.  Her child has severe behavioral feeding difficulties and she was experiencing some moments of concern, crisis, and even depression about the whole situation.  Her child has made incredible improvements, and the mom has also made incredible improvements - but the whole situation remains extraordinarily acute.  I tried to call the mom back but only got to leave her a message.  I tried my best to be upbeat and positive and supportive and helpful.  I hope it will be enough until I get to see them again.

As I hung up from leaving the message I started thinking about sustainability again.  Maybe I could tell the family that chicken nuggets and hot dogs are not part of a sustainable diet.  Constricted food choices is a real problem for this child but maybe if I approach if from the angle that he can save the planet by eating more veggies that I can make a dent in his behaviors.  Maybe this is the kind of reflection that Whittaker was suggesting.  Just think: my counseling about the evils of chicken nuggets and hot dogs might enable this family to experience a deeper meaning about their mealtime routines.  I started getting excited about these new intervention strategies!!

Then I thought that maybe I could change his food-throwing behaviors by pointing out that there are hungry children in the world and that it is not sustainable to waste food when there is such an inequitable distribution of nutrition around the globe.

He is only three though.  I don't know if he will understand. 

I guess I am still struggling with how to apply these ideas about sustainability.  Maybe I will get better at it with a little practice.  I really don't want to be small-minded and I want to be an informed and globally connected practitioner.

I would like to see some of the sustainability promoters out on the lecture circuit telling us street-level practitioners how to make this happen.  I would like them to tell us all their real life case studies.  Is there a CPT code that we should be using for 'ecological occupational therapy??'  Can we reduce our carbon footprint by going back to the days of low tech craft work - and then our patients can take their tile trivets home and actually use them!  But should we only do handwork and should we avoid using a kiln?  Kilns consume an awful lot of electricity.  Maybe we can do more leather work as we pare down our farm animal populations?  There are so many exciting possibilities here on how we can be sustainable!!

We all have tremendous responsibility for stewardship.  I actually agree that we should be environmentally mindful.  I think we also have a tremendous responsibility for stewardship of our profession's scope of practice and what actually constitutes occupational therapy.

The halting and sobbing between words in that mom's message today keeps snapping me back to reality.

I think it is the pragmatic voice inside my head.  Maybe this is all just nonsense. 


Whittaker, B. (2012). Sustainable global wellbeing: A proposed expansion of the occupational therapy paradigm.  British Journal of Occupational Therapy, 75(9), 436-439.