Physician practices have been hit hard by the COVID-19 pandemic, with many of them reducing office hours and seeing only the most urgent patients, or spacing patient visits to increase social distancing, or increasing telemedicine capabilities.
But how are physical therapy (PT) practices -- normally a very hands-on specialty -- adapting to a COVID-19 world?
It hasn't been easy, said Alice Bell, PT, senior payment specialist at the American Physical Therapy Association (APTA). "Very early in the pandemic, we were seeing a large number of cancellations, particularly in outpatient settings," Bell said in a phone interview, noting that many PTs provide care in other environments, such as nursing homes and hospitals. "Many people were canceling due to risk of exposure and stay-at-home orders."
Those outpatient facilities that are staying open are taking special precautions, she said. "They're scheduling patients further apart, utilizing personal protective equipment (PPE), and screening patients, so if they have signs and symptoms or have been in high-risk areas, they're advised not to come to the clinics."
To protect patients, clinics "are at a heightened level of disinfecting everything between patient uses, and if there is equipment for which that's not an option, that equipment is not being used," she said. However, "there are some challenges with continuing to provide care associated with continuing access to PPE.... It was the reason early on that some clinics just had to close their doors. The risk was too great to the provider and patient to perform face-to-face care without that equipment."
Telehealth Option
For those who don't want to or can't come into the clinic, telehealth has been a good option, she said. "For the patient who requires manual therapy techniques, we can't meet their needs in a telehealth visit; however, much of what we do goes beyond that, such as assessing an individual, helping them modify their environment, identifying alternative strategies, and helping guide patients through their exercise prescription," said Bell.
For example, "Even though we can't put our hands on the patient, we can ask them to perform actions, and looking at the action, we can make a determination about muscle strength," she said. "Someone who can't rise from their chair has lower-extremity muscle weakness, so we can still prescribe effective strategies in the form of exercise and functional activities they can perform to address movement changes."
PTs can make other recommendations as well, she continued. "We can look at posture, movement, and how the individual is walking -- say, if they're transferring from a walker to a cane -- and we can advise them on the right fit for their equipment. And if they have caregivers supporting them, we can advise them" on dealing with the patient's activities of daily living, Bell said.
Karen Litzy, DPT, is one physical therapist who has made good use of telehealth. Litzy is in New York City and doesn't normally work at a clinic; instead, she visits patients at their homes or offices. This works especially well for child and adolescent patients, she explained in a phone interview. "Here in New York, kids are so overly scheduled that parents like to have me come to them, so they don't have to take them to one more thing." But that's no longer possible, said Litzy, who is also a member of APTA's private practice committee.
Making the Transition
To make the change, Litzy said she "emailed each patient individually, both to check in and to let them know I'd be transitioning to telehealth," and to see which patients were comfortable with doing it. Litzy then called those patients who were interested "and talked about how it would work from their end and from my end."
Although she was a little nervous about it initially, "I've been pleasantly surprised because clients love it," Litzy said. "They not only enjoy the sessions, they're making improvements, having gains." About half of the patients have signed on so far. "Some clients say they'd rather wait and see me in person, and that's fine; I'm not going to pressure them into something they don't want to do," and some who refused initially have contacted her later about trying it out.
Making her apartment workable for doing telehealth visits hasn't been too difficult, Litzy said. "You want to make sure you have good lighting, so the patient can see you if you're demonstrating an exercise.... Luckily my apartment is not that tiny, and I've carved out space so I can do it on the floor or have room to move. I also have bands and weights, so if I need to demonstrate those, I just get one out."
Although many patients come to Litzy without a physician referral -- which is permitted in New York state for a limited number of visits -- they often do have a doctor, so Litzy will offer to call or email the doctor prior to the appointment to let them in on what's happening. "Doctors really appreciate that because they're getting a record of this patient," she said. "Then I also refer patients to them [as] one way that I try and create with physicians a win-win relationship."
Billing Issues With Medicare
Billing has not been an issue for Litzy, who doesn't take insurance; her patients pay for the session out of pocket and then submit the bill to their insurance company if they have one that covers it. But in many other physical therapy practices that do take insurance, a large number of patients are on Medicare, and that has been a problem when it comes to telehealth visits, said Bell, of APTA.
"Medicare has a list of eligible providers of telehealth, but PTs, occupational therapists, and speech therapists have never been on that list, although we've been working on it with Medicare for several years," she said.
The Centers for Medicare & Medicaid Services (CMS) has not previously had statutory authority to add these therapists to the eligible provider list, but that changed when Congress passed the CARES Act in the wake of the pandemic. With the act, "they've been granted that authority; we've been in communication with CMS and are hopeful they'll add therapists as eligible providers," said Bell. CMS has approved coverage of "e-visits" via online patient portal to discuss PT recommendations; Medicare also covers telephone assessment and management services, she added.
A CMS spokesman told MedPage Today in an email that "during the public health emergency, CMS allows certain practitioners (including physical therapists) to furnish telephone assessment and management services, e-visits and short telehealth visits, including remote evaluation of patient images/video and virtual check-ins. Additionally, under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, CMS has been allowed to expand the types of practitioners who can provide a broader set of Medicare telehealth services, including physical therapists, and we are working to implement this quickly."
Despite the available treatment options, some PT practices continue to struggle. "We definitely have heard from many members and non-members the challenges; people have been furloughed or let go," Bell said. "Therapists don't have large reserves like healthcare systems do and they're vulnerable, and right now PTs aren't eligible for extended family leave or sick pay because they're considered essential workers, so there are a lot of challenges.... They're starting to look at small business loans but some have had to close their doors, and there is some question as to whether they will be able to reopen."