Thursday, April 03, 2014

Update on early intervention coding and paraprofessional service delivery

Two years ago I blogged about NYS Department of Health emails that instructed the field in use of Level II HCPCS codes.  At that time I stated: 
Promoting use of Level II HCPCS codes can only mean they are incredibly misinformed and clueless OR they are throwing in the towel with trying to get reimbursement and they intend on replacing skilled services with services provided by non-licensed people with 'generic' developmental training.

It seems that we have received an answer in the form of a final response to a systems complaint initiated against the NYC Department of Health and Mental Hygiene on the topic of Embedded Coaching.  Click here to read that determination.

The allegation was that in NYC providers were being forced to address functional IFSP outcomes that fell outside of their scope of practice.  The Department of Health's determination was that NYC was in violation of 10 NYCRR 69-4(f)(3) regarding use of individualized approaches and they were also in violation of 10 NYCRR 69-4(a)(10)(v) regarding IFSPs that meet unique needs and methodologies.  As a result, NYC will need to revise its policies.

This is rather important because at the time of the email two years ago it was unclear if the recommended use of Level II HCPCS codes for developmental services would serve to pave the way for paraprofessional service delivery.  The determination of the DOH is unequivocal and it seems that there is no apparent interest in a paraprofessional service delivery model, at least in terms of how they are currently interpreting these regulations about individualized approaches, scope of practice, and methodologies.  It would be near impossible to square this determination with any future plan for a paraprofessional model.

What we are left with then is the alternate hypothesis that at that time of the email they had limited understanding of how Level II codes might be viewed by commercial insurance, even if they were being submitted by non-healthcare providers.  It seems that this is the more likely interpretation in light of this determination letter.  I understand that they at least attempted to clear the use of the Level II codes with OHIP and Medicaid, but with the way that so much Medicaid is administered through local managed care arrangements it is rather obvious that they did not really understand the complexity.  The ability to recoup money from a managed care Medicaid entity using non-standard codes is questionable, even if it is the intent to write an internal rule that these services can be billed to Medicaid. 

These are the kinds of complexities that gum up the billing process for service providers as well as commercial insurers.  We have given feedback to PCG regarding the issue of pre-filtering so as to avoid flooding commercial insurance with non-reimbursable claims.  When we talk to our local commercial insurance reps they indicate that the whole early intervention system has become a disaster precisely because of this kind of confusion.


Wednesday, March 26, 2014

Using celebrities to promote occupational therapy - 100 years ago?

According to Bill de Lancey (1958), a writer for the Geneva Times, "Mr. Barton was born in Boston, of a family steeped in the arts and letters."  Occupational therapists know that Barton was an architect and that he was an important Founder of the profession, but few know about the depth of his other talents and interests.

During the early 1900s, while he was encouraging Emily Post's literary career and while he was becoming more established in his own architectural practice, Barton also collaborated with others on musical and literary projects.

Isabel Barton (George's wife), wrote an AJOT article in 1968 that briefly mentioned some of these other collaborative products.  George Barton was very interested in Nero and wrote a play about his life called "Swift-Heeled Steeds."  The title likely refers to the famous line from the Iliad when Nestor states "The sound of swift-footed horses strikes upon mine ears."  This line was reportedly repeated by Nero as he was being chased down by his enemies, just before he committed suicide.

Barton collaborated with George Arliss on this project but it never came to fruition.  George Arliss was an actor and was the first one from England to win an Academy Award.  It is unclear how he and George Barton became acquainted.  George Arliss has a star on the Hollywood Walk of Fame.


Isabel Barton talks about a photograph that was taken of George Barton and George Arliss in her article, stating "This photograph is inscribed in G.E.B's handwriting, "George Barton selling the gold brick to George Arliss."  Here is the photograph:


The writing is a little difficult to read, but it clearly states precisely what was quoted in Isabel Barton's AJOT article.  I searched Arliss' (1927) autobiography "Up the Years from Bloomsbury" for any reference to the collaboration but could not find one.  Interestingly, the front cover of the book has Arliss' signature, which seems to closely match the writing on the photograph.  I suspect that the photograph inscription was actually written by Arliss and given to Barton as a gift.  Here is the Arliss book with signature for reference:


 A New York Daily Tribune article in 1910 quotes Arliss discussing the collaboration:

 Mr. Arliss, it seems, is very anxious to play Nero.  But not in any of the New plays which have been seen in London, 'but in a tragedy written by a brilliant American journalist, George Edward Barton.  His Nero is the most varied and the most natural one I have yet met.  No, I have not met the Elizabethan Nero play by Field, nor the Restoration one by Nat Lee.  All the stage Neros I have met have treated only what I might call the highlights of that strange personality.  The Nero in Barton's play is more the inside, or domestic Nero; not merely lurid or melodramatic.'"   

Around 1910 the word 'journalist' did not only refer to someone who wrote professionally for a newspaper but was also used to refer to a writer generally. 

It seems likely that Barton advantaged his social standing and connections for the benefit of his interest in occupational therapy.  Occupational therapy had an early supporter in George Arliss.  In 1923 Arliss presented 'The Green Goddess' as a fundraiser for the Ontario Society of Occupational Therapy at the Royal Alexander Theatre in Toronto (Friedland, 2011).  The event was described as follows (Modern Hospital, 1923)

We had a theatre night for which we were fortunate enough to secure the play "The Green Goddess," presented by George Arliss. In his praise of occupational therapy. Dr. Primrose, the dean of the faculty of medicine, gave a very interesting speech between the acts about the workshop and the work with civilian patients. His Honour, the Lieutenant Governor of Ontario and Mrs. Cockshutt granted their patronage for this occasion. It was a decided success socially and financially.

Although there is no documentation confirming the connection, it seems likely that Barton and co-founder Kiddner, who was an architect from Canada, had some influence in making this possible.

It may be interesting to occupational therapy conference attendees that even 100 years ago it was common to solicit the support of famous celebrities to bring attention to your cause!


References:

Barton, I. (1967). Consolation House, Fifty years ago. American Journal of Occupational Therapy, 22(4), 340-345.

de Lancey, B. (1958, May 9). George Edward Barton: Undaunted cripple's courage aided others. The Geneva Times, p. 2.


Friedland, J. (2011). Restoring the Spirit: the beginnings of occupational therapy in Canada, 1890-1930, Montreal: McGill-Queen’s University Press.

Homer (1924). The Iliad with an English Translation by A.T. Murray, Ph.D. in two volumes. Cambridge, MA., Harvard University Press; London, William Heinemann, Ltd.

Modern Hospital (1923). Roll Call - Canada.  The Modern Hospital, 21(2), 56.

New York Daily Tribune (1910, September 25).  The Theater.  Stage Notes: Concerning plays and players here and there.  New York Daily Tribune, p.6

Monday, March 24, 2014

Assistance requested with reading Emily Post inscription

Emily Post continued her literary career and in 1910 An Eagle's Feather was published. 


Apparently, she was still in contact with George E. Barton.  Here is a copy of the inscription to him in this book:



I am having a little difficulty with reading the print - it seems that Emily Post is stating her dissatisfaction with something - I was assuming it might be with the cover picture?  If anyone has any good guesses on what she was referring to I would love to hear opinions.

Whenever I can't read someone's writing I am always surprised to find out how it was so apparent to someone else - and then in looking at it a second time I don't know why I didn't see it!  Any help with this is appreciated.

Wednesday, March 05, 2014

Whitewashing the status of the NYS Early Intervention Program

In response to questions by members of the Legislature as part of the February 3, 2014 Joint Budget Hearing on the 2014‐15 Executive Budget for Health/Medicaid, the New York State Department of Health Early Intervention Program provided a progress report with the transition to the State fiscal agent.

No one stopped to think that self-assessment for progress reporting might not be the most accurate measure. 

Perhaps the most shocking misrepresentation in the report was regarding timeliness of payment.  They report that 2013 fourth quarter mean time to payment was 14 days following claim submission.  As a mean involves calculation including all ranges of payment, reporting a number without capturing the full range of data is a an absolute statistical manipulation.  A more reasonable and reliable statistic is to look at second quarter payments, which hopefully have all been compiled and adjudicated, except for extreme outliers.  That statistic is that the mean payment time was 47 days, which is much more consistent with reality that I have experienced.

I would like to congratulate the Department of Health for finding a way to report that their fourth quarter payments are happening within 14 days of billing.  It is a stunning claim and I suspect that they are hoping we have a dumbed-down legislature who all have heads swimming with common core math methodologies.  Reasonable people will understand that reporting descriptive statistics without gathering a full range of data is like patting yourself on the back for catching a nice large mouthed bass that you put in your own fish tank.

Only in government can you make such a vacuous claim and consider it reasonable.

Try this unreported statistic on for size:  In 2012 the total number of claims to the Early Intervention Program was 7,815,366.  In 2013 the total number of claims to the Early Intervention Program was 7,220,073.  According to the report, the 'claims' statistic is a proxy measure for the level of services delivered to children.  The statistic that is not reported is that there was an 8% decrease in the number of claims in 2013.  It would be hard to state that everything is 'just fine' if you talk about that inconvenient truth - so they just left that statistic out of the report.  Maybe they hope that people won't be inspired to do the math.

How about this: The number of billing providers decreased from the start of the Fiscal Agent process in March 2013 from 1,509 providers to the December 2013 level of 1,027 providers.  DON'T WORRY, says the Department of Health!  They tell us in the report "The decline in the number of billing and rendering providers from Q3‐2012 to Q2‐2013 reflects the removal of inactive providers from the EIP provider database at the time the Department implemented the 4/1/13 changes in the program and established direct agreements with each provider."  OF COURSE they have some magical way of knowing that these are all inactives?  And NONE of that 30% loss had anything to do with the State takeover and Providers bailing out of the system?  Again, it is an insult to everyone's intelligence and an obviously lopsided claim in an attempt to paint a picture in the best possible light.

Interestingly, the number of rendering providers over the course of the last year has been stable.  The Department of Health just can't help itself from trying to shine up this statistic: "This likely reflects a consolidation of rendering providers in the program into fewer billing agencies and independent providers while maintaining level capacity of rendering providers in the program."  Doesn't that sound innocuous and cozy?

Here is the reality: the reason why the numbers of rendering providers stayed essentially constant and the number of billing providers decreased is BECAUSE THE DEPARTMENT OF HEALTH SYSTEMATICALLY DESTROYED THE PRIVATE BUSINESSES OF SMALL AND INDEPENDENT PROVIDERS.  The small and independent providers had nowhere else to turn, so they were subsumed into large agencies, and their entrepreneurship has been CRUSHED.

We just won't talk about the fact that these small and independent providers were almost all women-owned private businesses, because that would contradict Governor Cuomo's claims of NY being a business-friendly environment.

Here is a final statistic that requires some analysis.  According to the report, 89% of all claims in December 2013 were adjudicated within two months.  That is up from 55% in May 2013.  That sounds good on paper, doesn't it?  Almost 90% of claims are being paid within two months - and there was a lot of improvement since the start of the Fiscal Agent Process!  Here is a little business lesson for everyone - and I hope the fine people in the legislature can understand this.  There is this little thing in business called a profit margin.  That profit margin is the amount of money that businesses get to keep for themselves after all the expenses are paid.  According to an article in Forbes, the average profit margin for therapy offices was 10.6% (http://www.forbes.com/sites/brettnelson/2011/02/10/the-most-profitable-small-businesses/).  This number might sound small to people but it is a rather healthy margin in context of most businesses.  However, that margin reflects the performance of a full range of therapy businesses.  I suspect that private PT offices make a lot more money than an early intervention service.  Still, that 90% payment level within two months takes on a very different meaning when you see that the margins for these companies are now under constant threat.  This is particularly true with early intervention, where the VAST majority of costs are going directly into staffing - and guess what - staff who work for an agency are not interested in being told that NY State hasn't made a payment yet.  Again, the reality is that the payments used to be FULL and IN REGULAR TIME INCREMENTS.  Now they are not - and that is precisely why there was a die-off of small and independent practices and this is also why even the large agencies are under duress.

Again, the Department of Health attempts to sweep all this information under the rug.  They applied a band aid to the problem last year in the form of the so-called 'Safety Net Payments.'  As the Department of Health is a governmental agency they obviously fail to understand that businesses are not interested in barely scraping by and trying to subsist on the band aid solution of a Safety Net Payment.  Again, none of this is reported on or analyzed correctly.

So we have a total whitewashing of the status of the New York State Early Intervention Program.  Don't expect anything to change, because Governor Cuomo is happy to have everyone gnashing their teeth over fracking and marijuana.  Trust me, he is hoping people won't learn the real truth about what he has done to Early Intervention.

Saturday, March 01, 2014

More research on effects of weighted vests on attending behaviors.


I was very happy to see another article on weighted vests in the current issue of AJOT (Lin, Lee, Chang, and Hong, 2014).  The last opportunity we had to look at this issue was the excellent pilot study completed by Collins and Dworkin and published in the November/December 2011 AJOT.  In that study (reviewed here) the authors found that the weighted vests were not effective in increasing time on task, but cautioned that the results should be generalized cautiously owing to the small sample size and participant selection process.

The current study, completed by colleagues in Taiwan, employed a much more rigorous randomized and two period crossover design with a much larger sample of children.  110 children participated in the study that measured their performance on the Conners' Continuous Performance Test and recorded behaviors during weighted and non-weighted vest wearing conditions.

The researchers made good attempts to control for bias by blinding the video coders to the weighted vs. non-weighted condition.  Additionally, the Conners itself is an objective measurement of attending skills.  They also used the two group design that presented the weighted vs. non-weighted conditions in reverse order to control for practice effect.  Finally, age and gender were non-factors despite the random assignment.

The children wearing the weighted vests made fewer omission errors and had improved response time.  The omission error rate is something that has direct functional impact and can probably be fairly extracted to a point of relevance in a clinical context.  It is difficult to know the clinical significance of the response time improvements because the differences are measured in milliseconds.  That is an issue I am not sure how to resolve, and it would be interesting to hear other people's opinions on this.  There was no difference between the groups on commission errors (a measure of impulsivity).

The researchers make appropriate note of some potential limitations, but their design still represents a significant step forward from what has previously been done.  They make note that there was not a 'no vest' condition but that would create blinding problems for video coders.  I think that the steps they took to use a non-weighted vest as substitute were reasonable.  They note that there was no control for subtype of ADHD, and I agree that this could be potentially important.  We know that ADHD is not a heterogeneous condition, and it is possible that different factors can contribute to the diagnosis.  For these reasons I think it would be very helpful to separate out Inattentive type from Hyperactive-Impulsive type - it would yield much more valuable data in case the neurophysiologic underpinnings of these types are different.

One very important consideration is whether or not the controlled environment and singular focus of the testing protocol was a mitigating factor that helped some children.  So, the question I had after reading this was: given that these findings are notably different from other studies, is the weighted vest condition only helpful when all other environmental and contextual distractions have been limited?   Using the Conners in a controlled context is nothing like the real-world context of the classroom, and this is an important confounding variable to consider.  For this reason I still liked the Collins and Dworkin methodology of videotaped recording and behavioral observations in the classroom.  Did the previous researchers not find any functional impact of the vests because the typical classroom distractions override any potential benefit that might have been seen if the testing conditions were more artificial like the current study?  Again, this is where the sub-typing analysis would be very helpful, because there is an open possibility that Impulsivity types are simply helped less by weighted vests, particularly in complex classroom environments where distractions are constant.

I don't know that I will make a sudden jump to wanting to use weighted vests, but in my opinion this is an excellent research study and it really gives us a lot of information to think about.  I commend these authors for this excellent progression of research in this area and for the very conservative and reasonable implications that they ascribe to their findings.  I hope that they continue with this research and strongly suggest that all OTs watch for excellent work like this that helps us better frame our clinical decisions.

References:

Collins, A. & Dworkin, R.J. (2011). Pilot Study of the Effectiveness of Weighted Vests. American Journal of Occupational Therapy, 65(6), 688-694.

Lin, H., Lee, P., Chang, W., and Hong, F. (2014). Effects of weighted vests on attention, impulse control, and on-task behavior in children with attention deficit hyperactivity disorder. American Journal of Occupational Therapy, 68, 149-158.

Thursday, February 13, 2014

How George Barton helped to launch the literary career of Emily Post

When you say the name “Emily Post” most people automatically think of her contributions as ‘Miss Manners.’ Although they were actually very close in age, it is probably a forgotten fact that George Edward Barton acted as her “Godfather” and editor who helped to launch her literary career.

A very reasonable question is “How was George Barton associated with Emily Post?” In 1889 Emily Price (Post) was a debutante and her arrival on the social scene is well documented in various New York newspapers of the day as well as summarized quite thoroughly by Claridge (2008). At about the same time, George Barton was riding a bicycle through the English countryside, whistling operatic arias and singing with King Edward VII.

Tuxedo Park is likely the point of commonality that brought George Barton and Emily Price (Post) into contact with each other. Emily Price’s father, Bruce Price, was also an architect and his most famous work involved the design of the Tuxedo Park community, as commissioned by Pierre Lorillard (Claridge, p.50).

Bruce Price was a contemporary of R. Clipston Sturgis, a famous Boston Architect. Price and Sturgis were both members of the Architectural League of New York. Sturgis was President from 1889-1893 and Price was President from 1897-1899.

Upon the completion of his apprenticeship, it is presumed that Barton worked as an architect and became associated with Sturgis. This presumption is based on the fact that Barton ultimately joined him in practice in 1902 (Commercial and Financial New England Illustrated, 1906). Sturgis and Barton had two offices: one in Boston and the other in Tuxedo Park, NY.  It is this association that likely brought George Barton to Tuxedo Park.

It is also likely that Barton had a home in Tuxedo Park. He is listed as a member in the Tuxedo Club in 1902. As an additional point of documentation, George Barton is noted as ‘arriving’ at Tuxedo Park in a 1905 article in the New York Times that documents the comings and goings of society elites in the ‘social pages.’

There is no mention of George Barton in the Claridge biography of Emily Post. However, there is documentation of their relationship in a newspaper article from The American Weekly (1949):

One day George Barton, a very old friend and one of the architects for whom she made several models, said to her: "You have always written amusing letters. I am sure you could write. By the way, where are those letters you showed me once that you wrote to your father from Europe? They were full of amusing details. Perhaps they might make a book. Let me look at them again."

 Not really believing them to be of any use, she fetched the letters. Little by little, with his help, she actually did make them into a book by writing a fictional beginning and end, and by running the thread of a romance through it. The hero's name was Lord Bobby Kirth!

 Her struggle with the first chapter is, perhaps, the key to her success. She rewrote it 27 times. When her critic then pronounced it acceptable, his comment was, "You'll write!"  

Interestingly, the Claridge biography mentions a George Barr Baker several times as the pivotal person who served as editor for her first book ‘The Flight of a Moth.’ This inconsistency would be difficult to reconcile, were it not for the inscription she wrote in a copy of the book that she gave to George Barton, that is currently in my care. Here is a picture of the book:




The inscription reads:








 The combined facts of the American Weekly article, the inscription in The Flight of a Moth, and the fact that these were all found among George Barton's possessions are strong indicators that the 'G.B.' in the inscription is referent to George Barton.

It is curious that she refers to herself as Barton's 'Goddaughter' but the Claridge biography provides very important details that may explain this.  Pierre Lorillard was Emily Post's true Godfather, but his scandalous behavior certainly caused her to re-consider the value of the association, despite the fact that he had been her benefactor.  Shortly after the Lorillard scandal and his death, her father also died.  The Flight of a Moth was published in 1904, at the same time that she was experiencing these other losses and very near to the time that her own marriage was dissolving.  It is likely that as a 'longtime friend' George Barton was a source of support and encouragement for her through these difficult times.

Based on all of this documentation, it seems evident that George Edward Barton was an important figure in Emily Price Post's life.  Just as with the presence of the Louisa May Alcott photograph, the fact that he kept this photograph of Emily Price Post is also an indicator of the significance of their relationship.






 References:

Architectural League of New York (1913). Annual Report of the Officers and Committees of the Architectural League. London: Forgotten Books. Available online at http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=14&ved=0CDYQFjADOAo&url=http%3A%2F%2Fwww.forgottenbooks.org%2Fdownload_pdf%2FAnnual_Report_of_the_Officers_and_Committees_of_the_Architectural_1000153702.pdf&ei=CFX8Ut62N4mMyQHnvYCgCw&usg=AFQjCNEj9iw-Afl6XL2EAc9VVWNNTGhN7Q&sig2=tzCgAdniafNJvvTqp_iHeQ&bvm=bv.61190604,d.aWc&cad=rja

Claridge, L. (2008). Emily Post: Daughter of the Gilded Age, Mistress of American manners. New York: Random House.

Commerical and Financial New England, Illustrated. (1906). The Boston Herald. Retrieved online at http://books.google.com/books?id=EXRPAAAAYAAJ&pg=PA254&lpg=PA254&dq=tuxedo+park+george+barton&source=bl&ots=2xwSDu4e2t&sig=dy2aTMjj-k1dP6vHQZoVbPq3IK0&hl=en&sa=X&ei=-ZTpUuTuAtS0kQfU2oGQBQ&ved=0CEUQ6AEwBA#v=onepage&q=tuxedo%20park%20george%20barton&f=false

Engle, W. (1949, February 6). The Emily Post Story. The American Weekly, pp 18-19.

New York Times (1905, June 11). Retrieved from http://www.newspapers.com/newspage/20324167/

The Tuxedo Club (1908). The Tuxedo Club Book. Retrieved from http://www.thehistorybox.com/ny_city/society/printerfriendly/nycity_society_club_1908_article00197.htm