Welcome Back - Been a While

I know many are wondering what has happend to PTManager Blog.  

We've been off ine for over a year. is what happened.


We got lawyered!!


One of our pages had an image that a photo studio (incorrectly) felt was their property.  


We got papered and hung up with all the legal nonsense.  The whole deal took over a year and we were advised to suspend operations until it was resolved.


We won and now we are back.


More to come soon on real content but...just to get you started, here is a link to a great video I did recently on Performance Management.  I think you will like it.





Peter Kovacek


Leadership Development

I just returned from weekend with APTA's Leadership Development Committee.

This is a VERY important initiative for the APTA and the Profession.

Great weekend. Great plans to ‪#‎MoveForward‬ the profession.

Can't wait for what's next.  Stay tuned here for details as they become available.


Recruitment Ad: Clinical Manager for In Home Rehab Detroit


We'd like to invite you to contact us to discuss the newly created position of Clinical Manager for In Home Rehab Detroit.

In this position, you will be responsible for all clinical operations - Physical Therapy and Occupational Therapy - in our 8 Metro Detroit area In Home Rehab Practice locations.

This position will offer you an amazing opportunity to make a difference in the practice and in our professions as you will be very actively involved in setting the strategic and operational direction of our practice.

This is a new position for us at In Home Rehab.  Up until now, we have had supervisory positions in both PT and OT that reported directly to one of our 2 therapist owners.  We are moving to a different leadership model with a Clinical Manager, Business Manager and lead therapist positions in each of the therapy disciplines.

This position has virtually unlimited potential for professional growth and will be strongly supported by our owners. As owners, we plan to continue to be very actively involved in our practice but to focus less on the day to day operations and more on business development = both locally and nationally.

For over ten years, In Home Rehab has been a national leader in geriatric rehabilitative care.  
We are active in practice in multiple Metro Detroit locations.
Our focus locally is in providing outpatient services within the comfort and convenience of patient homes.  
Typically, we set up small but well equipped clinics in Independent Living Centers so our staff and patients have the advantages of outpatient care without the inconvenience of having to travel to a typical outpatient therapy location.  When needed, to insure a continuum of care, we also contract with quality home health care agencies to provide therapy services to our patients while they are under a HHA plan of care. Additionally we have national practices throughout the country that are supported by our headquarters right here in Southeastern Michigan. 

The successful candidate for this position will need to be an experienced Physical or Occupational Therapist with a proven track record of leadership and management. Clinical expertise in Geriatrics and previous experience in Home Care and/or Outpatient services will be needed as this position will also be approximately 50-60% clinical care. 

We are seeking a highly motivated professional who will support and lead our therapy team.  If this sounds like a good job match for you and you would like to discuss this opportunity further, please contact us immediately.  

All the Best

Peter R Kovacek, PT, DPT, MSA
Mike Renema, PT
Owners, In Home Rehab.
voice: (586) 774-5774

Clinical Decision Making: Part I | Science-Based Medicine

I practice in a university clinic which functions partly as a tertiary referral center, which means we get referrals from other specialists. I also get many referrals for second opinions. Sometimes the entire cause for the patient’s desire for a second opinion, it seems to me, is the simple fact that they did not understand the reasoning of the previous specialist. They were given a diagnosis and a course of treatment, but not an explanation of how their doctor arrived at those conclusions.

I am not being judgmental – different practices are under different pressures and time constraints, and it can be very difficult to gauge a patient’s understanding. Often the physician and the patient are proceeding based upon differing assumptions and narratives that are not expressly stated. The doctor may think they have explained the situation entirely, but simply did not confront misleading assumptions they were not aware their patient had.

This is part of the advantage of engaging the public about health issues and confronting pseudoscience, myths, and misconceptions – you develop a deep awareness of how the general public thinks about medicine.

Carl Sagan warned against scientists becoming a “priesthood” with inaccessible knowledge and jargon, and this applies to the applied science of medicine as well (perhaps especially). We need to engage with the public so that there is a general understanding of not only the findings of science but how science works. In the context of medicine, this means understanding clinical decision making – how doctors think.

Toward that end I plan on writing a short series of posts that explore various angles of clinical thought. These are talks I have had with medical students, residents, and my patients, to make my thought process as transparent as possible. I have found it to be extremely useful and a worthwhile investment in time.

The Dr. House Syndrome

Patients often come to their doctor’s visits with a hidden narrative, a narrative I call the Dr. House approach. This is a narrative the public has largely learned from watching doctors on TV. It is also a perfectly reasonable narrative, and is not wrong as far as it goes. It’s just very narrow and incomplete.

The narrative is this – a patient has an illness (a certain set of symptoms), and that illness is caused by a specific pathological process or disease. The job of the physician is to be smart enough to make the correct specific diagnosis, which will then lead directly to a cure and resolution of the illness.

When this sequence of events does not occur or fails for some reason it is solely due to the fact that the physician simply did not make the proper diagnosis, so they should try again, order more tests, or refer the patient to someone with greater knowledge or more appropriate expertise.

On TV at least, Dr. House always eventually makes the correct diagnosis and saves the day.

Sometimes this is in fact how medicine works. In fact doctors love telling each other stories about the complex or difficult case that they eventually diagnosed, especially when that further lead to a cure, or at least an effective treatment. Often these stories are formally told as case reports or presented at conferences. These are fascinating stories because they are the exception, rather than the rule, of our day-to-day practice.

Other Clinical Pathways

While this is one possible pathway that diagnosis and treatment may take, it is not the only legitimate pathway. Here there is much variability by specialty. For most specialties, however, most patients will present with common ailments and diseases (common things are common – it may seem obvious but we do have to constantly remind ourselves of this – in fact this one point is worthy of its own post).

Diagnosing common conditions often is a matter of making a specific diagnosis and treating it. Patients have hypertension, diabetes, multiple sclerosis, etc.

What I am discussing here are those patients with something other than discrete, common, and easy to establish diagnoses. How do we approach such cases?

Ruling Out

It is often as important to know what a patient does not have as knowing what they do have. We order some tests to rule out diagnoses that are possible, serious, and/or treatable. (An algorithm as to which diseases to consider and which tests to order can be the topic of a future installment in this series.)

It was surprising to me when I first realized how upset some patients can get when you inform them that they do not have a horrible diagnosis. I actually had one patient cry when I gave them the “good news” that their test was negative. That’s because I had yet to understand the narrative under which they were working. They were thinking diagnosis leads to treatment leads to cure – no diagnosis, not treatment.

I have since learned that I have to explain to patients as I am giving them their results that it is a good thing when certain tests come back negative. They do not want to have the diagnoses I am ruling out.

Further I explain that it is sometimes better to have no diagnosis than to have a bad diagnosis. Patients in whom all the tests come back negative (depending on the clinical situation) often do better than those with a specific diagnosis.

Further still, it is often not necessary to have a specific diagnosis in order to treat an illness. (Again, this is very specialty specific – surgeons do need a specific diagnosis most of the time, whereas neurologists often have to proceed without one.)

To Treat Without a Diagnosis

To summarize everything above, an alternate narrative to diagnose, treat, cure is this: Rule out everything bad, understand the phenomenology as best as you can, then treat symptomatically. This may seem less satisfying, but it is often the preferable situation (again – you do not want to have a horrible diagnosis just to have a diagnosis).

Migraine is an excellent example of this. Patients present with a set of symptoms that we recognize and categorize as a migraine. There is a great deal of variability, however, and many patients may present with an atypical migraine, or migraine-like syndrome. There is no way to objectively make this diagnosis, no positive diagnostic tests.

The diagnosis is partly based on understanding the phenomenology – what kind of process is happening. It is also partly based upon ruling out other things that can cause similar symptoms (like a brain tumor). We then treat based upon a categorical diagnosis – the kind of process that is likely happening. Response to treatment then becomes the best confirmation we can get that the diagnosis is probably correct.

This may all sound very unsatisfying, but this just exposes yet another difference between public and expert narratives. Doctors learn to think in terms of – what is likely to happen. How is this patient’s story going to play out. After years of practice you develop a perspective on this, and you realize that it is not a terrible thing when all the tests come back negative. Those patients may do quite well.

Another way to think about this approach is this: The diagnostic workup in focused on finding active processes and pathology, especially those that are treatable. We then treat what we find, in addition to treating symptoms to improve quality of life. At no point in this process do we need to establish a specific diagnosis.

For example, I see patients with nerve damage (neuropathy). First I establish that the patient’s symptoms are due to nerve damage and characterize that as best as possible. Then I look for any active process or anything treatable that might contribute to poor nerve health. I may find that the patient has a low vitamin B12 level. For many patients I still have no idea if the low B12 is causing or contributing to their neuropathy. Except in advanced cases, this is difficult to determine, and I won’t get a nerve biopsy just to confirm this. Instead I will just replace the B12.

Categorical and Vague Diagnosis

Another important distinction to make is that not all diagnoses are created equal. This too will be the topic of a future post, but for now suffice to say that there are hierarchies of diagnosis, and different types of diagnosis. Not all diagnostic labels refer to a specific and distinctive pathological entity. Sometimes we can determine what type of process is happening (an inflammatory process, for example) but not get more specific than that.

In other words, making a diagnosis is not a black or white, all or nothing proposition.

This approach to some patients has lead, in my opinion, to the creation of vague diagnostic categories. This is because we need something to label patients in whom we have ruled out everything specific. These categorical diagnoses can be useful, but also a trap if you treat them as if they were a specific pathological diagnosis.

Fibromyalgia is the poster child of this phenomenon, in my opinion. It is a convenient label for anyone with muscle and connective tissue pain (myofacial pain) that is otherwise undiagnosed. Sometimes clinicians will call such a label a “garbage pail diagnosis” – we throw everything in that we cannot label more specifically.

]This can be a useful placeholder, it can be useful to put the diagnosis into its proper category in terms of which kind of process is happening, and it is convenient short hand. In this case fibromyalgia may also be a specific disease, with specific findings, but it is used as a catch-all for any myofacial pain syndrome.

I prefer to use the term “myofacial pain syndrome” because it does not imply more specificity than actually exists. There is a bias, however, toward labels that sound like specific diseases.

Don’t Be Complacent

All of this is not to suggest that we should be complacent with less than complete knowledge. This is a tricky balance that also benefits from experience. We have to understand the limits of our knowledge and technology, and understand how to approach and treat patients in whom we will not make a specific diagnosis. But this should not lead to complacency – accepting too quickly that we don’t have a diagnosis.

The most important factors in determining how aggressive our posture should be toward making a more specific diagnosis is whether or not we have found specific pathology, and how the patient is doing clinically. If the patient is stable or improving, and/or responding to treatment, it may not be necessary or advantageous to continue ordering more diagnostic tests. If the patient is progressively getting worse, however, this suggests the need for more information.

Also, sometimes tests come back negative and sometimes they come back with abnormal but non-specific findings. For example, an MRI scan of the brain may find a “lesion” (a deliberately vague word) but not show specific features that would allow for a diagnosis of what the lesion is, exactly. We now have possible evidence of a pathological process, and this warrants more aggressive workup than if the MRI scan came back pristinely normal.


The goal of this series of posts is to help physicians and patients communicate more effectively by exploring and understand the various assumptions and narratives that each bring to the clinic visit. This is an exercise in metacognition – thinking about thinking, in this case thinking about how doctors think.

As you can see, it quickly gets complicated. I have raised many points here each of which deserve further exploration. The comments are likely to raise points and questions that I can also explore further in future posts.

In approaching this series the most challenging aspect was figuring out how to divide up the various topics. They all are interrelated in a web of decision-making. Hopefully the result was not too disjointed, but I will attempt to keep referring back in future posts and hopefully it will all come together in the end.

Original Page:

Saved from Feeddler RSS Reader


How Medicare Fraud Became the Nation's Most Lucrative Crime - Page 1 - News - Los Angeles - LA Weekly

So it's no surprise that the 95-year-old nonprofit — formerly known as Houston Negro Hospital — shared the same broken finances as the people it served. Most patients couldn't pay their own way, leaving Riverside to survive off the rock-bottom reimbursement rates of Medicare and Medicaid.

At one point, it was losing $10,000 a day. That's when executives decided to cauterize the wound with the hot poker of fraud.

In 1996, the state of Texas accused Riverside of padding fees and billing for drug-rehabilitation services it never provided. Texas canceled $1 million in contracts and demanded that the hospital repay another $763,000. It also urged the feds to audit Riverside's Medicare and Medicaid payments.

Yet charges of fraud weren't enough for bureaucrats to close the spigot fully. The money continued to flow. It would take another eight years before the state had finally had enough. In 2004, it moved most of its drug-treatment contracts to more trusted providers, slashing Riverside's funding by 75 percent.

Unfortunately for the taxpayers, Riverside CEO Earnest Gibson III had friends in influential places. Congresswoman Sheila Jackson Lee, D-Texas, demanded an investigation of the cuts, calling on Gov. Rick Perry to restore the money. Perry, who had appointed Gibson to the Board of Regents at Texas Southern University, was happy to oblige. By the time it was over, Riverside emerged with another $3 million.

It wasn't until 2011 — 15 years after the initial accusations — that law enforcement got serious. That's when the feds nailed administrator Mohammad Khan, who confessed to enriching the hospital via a kickback scheme.

He'd been paying "recruiters" $300 a head to bring Medicare patients to Riverside's six psychiatric clinics. They arrived by the van load for daily therapy sessions they rarely qualified for, or received. Medicare picked up the $116 million tab.

When the scheme was discovered, the Center for Medicaid and Medicare Services (CMS) finally halted the hospital's payments. But in the eyes of Jackson Lee, a meager $116 million theft was hardly cause to rush to judgment. Her husband, Elwyn Lee, once served on Riverside's board. So the congresswoman again rode to the hospital's rescue.

"Even if more harmful acts prove to be true," she wrote to CMS, "an entire institution should not be penalized by the acts of one person."

In Riverside's case, that "one person" would abruptly multiply. Investigators discovered that, since 2005, the hospital had been swindling the feds to the tune of $22 million a year. Kahn ratted out CEO Gibson as his co-conspirator, and the feds also nabbed Gibson's 35-year-old son, Earnest IV, who ran one of the psychiatric clinics and was charged with billing nearly $700,000 for care that "was not medically necessary and, in some cases, not provided," according to prosecutors.

Kahn has pleaded guilty. The Gibsons and five others await trial on charges of fraud, conspiracy and money laundering. And by this time, Jackson Lee had no choice but to dial down her patron sainthood. She refused to comment for this story.

Another member of Congress is happy to talk. Kevin Brady, R-Texas, has been trying to draw attention to health care fraud in Houston since entering office in 2009. It seems that CMS, the agency charged with protecting Medicare dollars, had failed to notice that the city's private ambulance services were robbing the agency blind.

That year, companies in Harris County, Texas, billed Medicare $62 million for emergency shuttles. By comparison, New York City received $7 million for the same services. Brady's concerns went ignored until 2011, when a Houston Chronicle series dragged the scam into the light.

Think of the Medicare program as a bank that never bothered to buy a safe. Everyone from HMOs to drug dealers has been caught robbing it time and time again, stealing the kind of money that makes the sequester look like pocket change.

While the credit card industry uses data-mining techniques to flag fraud within minutes, CMS has allowed the most obvious schemes to run for years, rarely the wiser.

"Washington has long bragged that Medicare only has a 2 percent administrative overhead," Brady says. "But with that, we've paid a steep price in far too much fraud."

Given how often such blatant thievery goes undetected, no one's sure how much fraud there really is. Conservative estimates place the bill at $100 billion annually. The more adventurous peg the figure closer to $300 billion — three times what the feds spend on education.

It has left federal health care little more than an unlocked home, where street punks and gangsters, doctors and even states walk right in and help themselves to whatever's inside.

All you need is the government and your imagination

The stealing has become so sweet that Medicare fraud threatens to overcome drug dealing as America's favorite quick-riches pastime. Street criminals can easily pull in $25,000 a day without carrying a gun. Throw in modest sentences for getting caught, and it's the criminal equivalent of saccharine.

Take Cuban expat Armando Gonzalez, who served five years for dealing crack. When he got out, he started several outpatient psychiatric clinics in Miami with a scheme similar to Riverside's.

1 | 2 | 3 | 4 | 5 | 6 | All | Next Page >>