Friday, July 24, 2015

Celebrating TEN YEARS of occupational therapy blogging!

Ten years ago I posted this first entry:


Hi everyone...

This is the ABC Therapeutics weblog. We are occupational therapists in Western New York.

More coming soon...


Well it has been ten years!

Sometimes the entries were patient stories.  Sometimes they were opinions on professional matters.  Sometimes they were analyses and criticisms of the systems we work in.  Sometimes the entries were pithy and academic and sometimes they were pedantic and boring.

No matter what it all has been, I hope that I have been faithful to my mission of creating an ongoing experiment in a mostly open-source exploration of occupational therapy.  No ads.  No bias other than 'just me - '  straight shooting commentary from the hip of a street level practitioner.  Sometimes that resonated and sometimes it created enmity - but it is all dialogue and that is something that we all need a lot more of.

No matter what, it seems appropriate to take the opportunity to thank those who have read, debated, agreed, disagreed, pondered, acted, and  contributed by commenting or sharing ideas here.

I'll be re-linking some 'blasts from the past' all week as I celebrate this ten year achievement!

Here's to the next ten years!

- Chris

Tuesday, July 21, 2015

Open letter to the NYS Board of Regents on the OTD degree

The New York Department of State's Division of Administrative Rules (DAR) publishes the weekly State Register.  This document contains newly proposed amendments to state agency rules and provides interested parties an opportunity to comment on actions before an agency adopts each rule.

The July 1, 2015 Register contains a new rule that will authorize the conferral in New York State of the degree of Doctor of Occupational Therapy (O.T.D.).  There is a 45 day comment period that will soon come to a close.

The Register states that 
The purpose of the proposed amendment is to authorize the conferral in New York State of the degree, Doctor of Occupational Therapy (O.T.D.). The proposed amendment arose from a request to confer this degree by one of the institutions of higher education in New York.  The O.T.D. degree is recognized by the Accreditation Council for Occupational Therapy Education (ACOTE) and is an authorized degree in 26 states, which include California, Connecticut, Florida, Georgia, Massachusetts, Pennsylvania, and Virginia. Adding this degree will benefit occupational therapy students and practitioners in New York by affording them the opportunity to earn a doctoral level degree. The O.T.D. degree in New York will expand practitioners’ access to higher level research and lifelong learning, which ultimately translates to better client care in the profession. Because the O.T.D. degree is a new degree in New York, it is necessary to amend sections 3.47 and 3.50 of the Rules of the Board of Regents related to requirements for earned degrees and registered degrees.  The State Board for Occupational Therapy supports the authorization of this new degree title.

The argument that this degree is necessary because it is not available to NY therapists is a canard.  Many NY State practitioners have engaged distance education to pursue the OTD degree.  Offering the degree in NY serves higher education in NY and does little to nothing with regard to overall access to educational opportunities which are already plentiful elsewhere.

What the Register does not reference is the push from the Board of the AOTA to move the profession to a mandatory entry level OTD.  As most educational programs are 'credit heavy' this will be a default elimination of the masters level degree.  As one possible example, when students are presented with an option of completing an MS program in approximately two years or a doctoral program in approximately three years it is likely that they will opt for the doctoral program.  This dynamic has been discussed from a competitive standpoint by the AOTA Board of Directors when they stated, "The current high credit load in master’s programs makes it very difficult to add additional content in specialized areas of practice. At this time the occupational therapy master’s programs greatly exceed the average credit load of other master’s programs, prompting students to ask why their colleagues in other professions are graduating with a doctorate when, in most cases, they are only in school for 1 to 2 more semesters."

This fact makes the following statement in the Register incorrect:

The amendment simply adds a new degree option and imposes no costs on any parties.

In fact there will be significantly increased costs to students who will be cattle-herded into doctoral programs.  They in turn will attempt to increase the cost to employers because students will believe that they are entitled to high pay associated with their doctoral training.  That can increase the cost to consumers.

A Regulatory Flexibility Analysis was not required and not prepared because the proposed rule states that there will be no impact on business or local governments.  This is false.  Permission to grant this degree will ultimately lead to the elimination of the masters educational level and can increase costs at every level.

A Job Impact Statement was not required and not prepared because the proposed rule states that there will be no impact on jobs or employment opportunities.  This is false.  Increased costs are likely to lead to job loss and will encourage increased attempts by employers to use lower cost or alternative providers.  This will not meet the objective of improving quality of care to consumers in the State.

The Register states that "the State Board of Occupational Therapy supports the authorization of this new degree title."  However, they do not recognize the inherent conflict of interest that many State Board members have because they are employed by institutions of higher education, which would all profit from expanding their degree offerings and escalating the entry level degree.

The Register also does not address the fact that this matter is being internally debated within the occupational therapy profession but that there are extensive flaws in the process that have been documented here and here and here.  During an open forum at the 2015 AOTA Conference the vast majority of commenters argued against the OTD.  At this time there is no consensus on whether or not the entry level OTD should be encouraged.

This proposal from the members of the Occupational Therapy Academy in NY State is in direct contradiction to the overwhelming opposition to the OTD that was evident at that AOTA forum.  This proposal is an end-around the entire process because the escalated degree requirement will ultimately lock out other degree options, and the members of the Academy know this very well because the same scenario played out when programs moved from the baccalaureate to the masters level.

The Board of Regents is well aware of degree inflation and its negative impact on economies.  There is no compelling reason to expand this educational version of a nuclear arms race to the occupational therapy profession.  Health care costs are already spiraling out of control, and it is not necessary to contribute to this trend by encouraging over-training of health care professionals.

Occupational therapists should be concerned because the evidence cited and the comments from the field do not support this change.  I understand the retort that 'this doesn't mandate anything' but in fact we all know precisely where this will lead - and we should have veracity when we are promoting such large policy shifts.

Occupational therapists should also be concerned because this initiative is timed when nearly 30% of the workforce (that is located in pediatric/educational settings) is less likely to notice because they are employed in a pattern associated with the school year calendar.  Occupational therapists should also be concerned because there has been virtually no public comment on this matter from the State OT Association.  In fact, as previously documented, there is evidence that NYSOTA and AOTA are fully aware of this initiative because they have been copied on all internal emails between academic programs who have been discussing this change.  I do not believe that most occupational therapists in the State are even aware that this is happening.

At the time of this publication, this blog stand as the only place that is publishing this information to the occupational therapy community outside of the Register itself.

Constricted publication and notice serves the needs of the few - and hardly represents a democratic process.

There is no evidence that an OTD is necessary.  It will increase student debt, it may unnecessarily lead to economic costs to the State, and it does not meet the needs of consumers of occupational therapy services.  The proposal itself does not accurately reflect the broad range of concerns that are present about this change, and it should be rejected.

Comments will close on this proposal in the near term.  I encourage everyone to provide feedback on this proposal.  Data, views, or arguments may be submitted to:

Office of the Professions,
Office of the Deputy Commissioner
State Education Department
State Education Building 2M
89 Washington Ave.
Albany, NY 12234
(518) 486-1765

Tuesday, July 07, 2015

Occupational therapy and CPT coding

Different people are interested in the things that I do each day, and they are interested in them for different reasons.

The people who come to me asking for help with a problem are interested in whether or not I will be able to summon the requisite knowledge to address their concern (Competency Test A).  They are also interested in whether or not I am a 'nice guy who cares' while engaging in that process (Competency Test B).  As an example, this morning a mom wanted my opinion on how to solve a problem with the positioning of her child's head and neck, because of being tilted over to one side.  I have seen hundreds of cases of torticollis, but none of them are "routine" to me.  Every one of them is treated with as much seriousness and concern and diligence that I can muster.

If I treated them as 'routine' then I probably wouldn't take the time to meet the parent's Competency Test B (the 'nice guy who cares' test).  Fortunately I was able to summon the requisite knowledge and give the parent some treatment opinions.  As I was doing so I interacted with her children and made such an impression on the youngest that he wanted to give me a big hug when he left.  I passed all the tests!

The reason why I pass the tests is not only because of my knowledge about torticollis.  The problem is not only that his head is tilted to the side.  The problem is that it MIGHT stop him from running a fly route, craning his neck in every direction to find the ball, and then catching the game winning Hail Mary pass when he makes it to the NFL.  Nothing is routine when you are asked to help a parent with their concerns about their child.

Don't tell that to the insurance company though.  They are also interested in what I am doing.  Based on a proposed CPT coding system they want to know if what I am doing is a low complexity or a high complexity task.  I understand their interest because they are trying to find ways to develop coding systems that will control costs.

I am not really interested in their definitions of Value (Cost-Cutting).  On a moral level I don't know how to answer the question about complexity.

If it was a simple or low complexity problem then why would the parent be concerned?  I can state factually that parents don't seek out occupational therapy services routinely.  They tend to take care of a lot of things on their own.  In fact, this parent was working on the problem themselves for quite some time before they called me.

I understand that doctors measure complexity in mechanical ways.  Should I be doing that as an occupational therapist?  Is it correct to measure concern or complexity based on how many body parts are broken or impaired?  Do I start counting how many different ways the child is impacted?  Is it low complexity if the child just can't turn his head to one side?  Is it moderate complexity if his gross motor skills are delayed?  Is it high complexity because the parent is concerned that he won't catch the game winning touchdown pass and the Buffalo Bills will never win the Super Bowl?

Should I never consult the parents and shut out that data stream from my decision making?  Things get really simple when all we are concerned about is clockwork systems like degrees of motion in the cervical spine.  Is that what I am to be reduced to doing?

This weekend my lawnmower wouldn't start.  Single cylinder engines are pretty understandable, even for a novice like me.  The complexity is low.  I decided that it wouldn't start because the spark plug was fouled.  So I changed it, and the engine started, and the lawn got mowed.  Easy.

The lawn mower did not have a mom who was worried about whether or not her baby would make it to the Super Bowl.  It was just a lawnmower, and I think I even cussed at it once or twice while I was trying to get it fixed.    Low complexity stuff.

So as I consider this new proposed coding system that is asking me to rate complexity in my treatment of babies I think I will just protest and refuse to participate.  All of my cases are complex, and I was actually trained to consider them that way.  In fact, I was told that if I stopped considering the complexity of my patients that I might as well stop being an occupational therapist.

If I failed to consider complexity, I might miss something, and that is not an acceptable standard of care for an occupational therapist.

Occupational therapists should not be forced to be reductionistic thinkers who count up how many body parts are damaged or how many performance areas are impaired.

These cockamamie coding systems will come and go.  That is one benefit of having done this for 30 years.  I know better than to fall for the latest payment scheme and coding fad.

If the insurance company wants me to label and then fix something that is low complexity, maybe they can drop off their lawnmowers.

Otherwise, I plan on considering every single child I see as high complexity, and if your occupational therapist doesn't do the same, go find another one who will.