Evidence Based Rehab

Physical Therapists in MainE are fighting for their livelihood against the ever-growing bravado in procuring profits by denying more on more services to subscribers and cutting reimbursements to providers. AFTER PT's in MainE signed on to be providers for Anthem BC/BS, Anthem UNILATERALLY cut reimbursement to those same PT's by 20%. Although that is bad in-of-itself, strong-arming providers into reimbursement agreements that are barely at a level (and sometimes below the level) allowing for a consistent profit margin, it is not new. There are two other developments from this action that I find interesting.

The first is what happened when Anthem forced this rate cut on the PT's in MainE. Unlike our long history of passivity, the PT's stiffened up and said "no!" and now have a lawsuit against Anthem that is moving through the courts. I see this as analogous to the terrorized finally pushing the bully back. We may get our asses kicked in the end, but it's finally a step towards standing up for ourselves and our profession.

The second event related to this is the response by our professional organization the APTA. It appears from my vantage point that the APTA is keeping to itself on this issue. In my opinion, this is the perfect opportunity for the APTA to help by flexing some muscle and stand up for what we know is right. It seems we are taking the stance that we don't want to "offend" anyone so we'll just make like Switzerland and play neutral.

We need to support our fellow PT's if not for anything but to avoid becoming bullied just as they are.

Jason Harris

Labels: Anthem, BC/BS, Healthcare, Lawsuit, Maine, physical therapist

Anew website has been published providing information and resources on fighting chronic diseases. As we all know, the biggest impact on quality of life and health care costs are the treatment of chronic diseases. The website called "Promising Practices" comments that:

America faces an important crossroads in health care. The Partnership to Fight Chronic Disease, a diverse, national coalition of more than 100 partner organizations, is committed to raising awareness of policies and practices that save lives and reduce health costs through more effective prevention and management of chronic disease. We share common concerns about the incredible burden that chronic diseases place on families, the health care system, and the economy overall.

Though many understand the need for better ways to lower the risks of developing chronic illnesses and reduce the burden of illness on those already affected, they wonder how and where to begin. Innovators in schools, communities, workplaces, and the health care system are proving the value of addressing chronic disease in building a healthier America. Working together, we can develop innovative, common sense solutions to our current health care problems. We encourage you to use these resources to develop and support meaningful changes that will make a difference.

This appears to be a nice resource of patients and providers alike.

Jason L. Harris

Labels: education, Healthcare, Low back pain

More surgery, more drugs, and more injections are not what the doctor ordered.

Tallahassee, Florida, May 20, 2008 – When it comes to chronic back pain management patients should know that “less is more.” The American Pain Society at their annual meeting unveiled a current review on invasive procedures for the treatment of chronic low back. The scientific review concluded that most invasive interventions, including spinal joint injections, radiofrequency denervation, intradiscal electrothermal therapy demonstrated no evidence of effectiveness. Furthermore, surgical procedures for chronic low back pain demonstrated only small improvement in pain and disability but were accompanied by considerable risk.

"The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou."

“The American Pain Society panel has acknowledged the central role of an active physical therapy program in managing low back pain patients,” noted Timothy W. Flynn PT, PhD, President of the American Academy of Orthopaedic Manual Physical Therapists. “The key in chronic low back pain is avoiding too much medicine. There is no magic bullet but a combination of hands on care and an active exercise approach is the best solution.”

Labels: AAOMPT, evidence based medicine, Healthcare, LBP, Low back pain, physical therapy, public relations

Google has released their online health information service. You can navigate to it by clicking here. While I fully support individuals taking positive steps in understanding and becoming a participant in their healthcare, I hope this service is just a step for the layman to organize their knowledge of their health and not a step turn over control of a patient record to the individual themselves.

The legal ramifications of how to practice when the individual has complete control of how and what is entered into their health record is frightening.

What is your opinion? Great step or bad road to go down?

Jason L. Harris

Labels: Direct access, google, Healthcare, Open Access

Isn't the internet great? Now you can receive consultations for sacroiliac pain over the phone. While I agree general advice can be delivered via telecommunications (especially with an established patient) it seems to be a stretch to do the same for low back/SI pain. As PT's our greatest tools are our hands and our minds. Seems this patient care approach is eliminating 1/2 of those tools. What do you think?

Labels: Healthcare, LBP, Low back pain

Wow, I thought I'd found a candidate I could back. Not what am I going to do? I know this is not physical therapy related, but it is a prominent figure backing pseudoscience over evidence based medicine.

Here is McCain's statement from The Wall Street Journals Health Blog:

Going against the opinion of America’s top public health agencies, John McCain has suggested that autism may be linked to thimerosal, a preservative containing mercury that used to be common in children’s vaccines.

“It’s indisputable that autism is on the rise among children,” McCain (pictured) reportedly said while campaigning recently in Texas. “The question is, What’s causing it? And we go back and forth, and there’s strong evidence that indicates that it’s got to do with a preservative in vaccines.”

This despite every credible expert/scientist/clinical study that shows the opposite: NO LINK BETWEEN AUTISM AND THIMEROSAL

Jason L. Harris

Labels: Autism, EBM, evidence based medicine, Healthcare, McCain, Vaccine

A committee formed by the Osteoarthritis Research Society International (OARSI) released a document on what they feel are evidence based recommendations for treatment of hip and knee Osteoarthritis (OA). The stated goal of this committee was:

To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

A very noble goal indeed. What I'm excited about is that the committee did not include a single physiotherapist/physical therapist, yet our profession figures very prominently in most of the "non-pharmacological" treatment recommendations. The paper goes on to state, specifically, that referral to PT for symptomatic knee and hip OA was "strongly supported" and recommended by "100% of the experts" on the panel.

Good news for us. Now if we can get this into the hands of the public, all would be even better.

Jason L. Harris, PT

Labels: Direct access, evidence based medicine, Healthcare, OA, Osteoarthritis, physical therapy, special test

Arelease from the APTA states the NATA (athletic trainers association) has filed a lawsuit against them for "anticompetitive" activities. The main point relates to MANUAL THERAPY, specifically rib and spinal manipulation. Now, as the few of you that read my posts know, I'm a big believer you don't need 4 years of hot air and philosophy to manipulate the spine, but you do need to have an excellent background in systems review, examination skills, and a wide knowledge of differential diagnoses. Chiros have this and PT's have this, but I don't see this with ATC education. And I choose a "masters" level education, which is the "new and improved" ATC degree, to highlight this.

I make no claim that I could effectively manage the day to day sports injury needs of a sports team or walk the sidelines of a game and provide the triage care that an athletic trainer can. However, ATC's are beginning to push their limited rehabilitation education into the realm of PT, and I guess DC. This is just another example of people wanting more than they are willing to go to school and get the education for. Heck, internally we even exclude PTA's from MT courses because IT IS OUTSIDE OF THEIR educated abilities. Here is the statement from the APTA:

APTA Responds to NATA Lawsuit

The National Athletic Trainers' Association (NATA) on February 1, 2008, filed a lawsuit against APTA and the Orthopaedic Section, APTA, Inc. in the U.S. District Court in Dallas. The complaint alleges that the APTA and the Section have violated the antitrust laws by seeking to deny athletic trainers (ATCs) access to the market for manual therapy and by coercing physical therapists to refrain from educating ATCs in certain techniques. APTA's counsel is currently reviewing the complaint. APTA believes that the NATA lawsuit is wholly without merit.

Physical Therapy can ONLY be provided by lisenced PHYSICAL THERAPISTS. Not by ATC's who wish themselves physical therapists.

For more fun reading, here are some additional links:

• NATA's Letter to the APTA - laughable
• Addendum to the above letter
• APTA's letter to NATA
• NATA's Injunction Filing

What is sad, is that we NEED ATC's. They are an integral part in the healthcare field. However, they are not physical therapists and yet they not only want to act like PT's their informational pamphlets boast about how ATC can be abused for economic gains being used as PT's by physicians and hospitals:

The value of certified athletic trainers isn’t limited to the
sports field. While ATCs have worked with orthopedists and in
rehabilitation clinics for the past 40 years, they can provide
a great deal of assistance – and additional revenue – to a
hospital, physician office or clinic, whether it be a large,
university-run complex or a small, private practice.

Then from a "FACT SHEET":

1. FACT: All athletic trainers have a bachelor’s degree from an accredited college
or university. Athletic trainers are health care professionals similar to physical,
occupational, speech, language and other therapists.

Sure, and I have a Doctorate degree similar to medical doctors then. What? It's not? Somebody better tell the NATA then.

To me, it seems the NATA may be trying to convince the lay public that they are in fact physical therapists with out having to go to physical therapy school. I hope you don't make the mistake of taking your grandfather s/p CVA or your mother with a diabetic ulcer, or your uncle who is trying to recover from a heart attack to a professional with out the educational background to effectively, and possibly, safely treat them.

It one thing to wave the magic wand (ultrasound) over someone and educate them in therapeutic exercise (which I believe ATC's surely do well) it's another thing to claim to be on par with THE experts in neuromusculoskeletal evaluation and rehabilitation.

Labels: APTA, Direct access, EBM, Healthcare, NATA, woo

A'thank you' to Eric Robertson from over at NPA Think Tank for mentioning this blog in a recent post by him. This also was cross posted on the Evidence in Motion blog. His post was a follow up to his earlier post calling for more PT's to blog.

As a side note, his post also included a link to a blog written by Mark Schwall which has great insight and is easy to read. Check it out here.

Labels: blogs, Healthcare, physical therapy

Rising healthcare costs and the health insurance industries continuous push to maintain high profits have lead to higher and higher copays. Especially in PT where insurance companies aren't really sure what they are paying for. It's not uncommon for me to have patients come in with insurance benefits that require a $25-$35 copay per visit. Plus, there is usually some arbitrary visit limit to boot! Many patients balk at this, and our first reaction is to sympathize with them and help make excuses why they don't have to come in, or don't have to come in often. Is this the right approach, though?

A colleague and I just had a conversation today regarding this, and Larry Benz, coincidentally, posted his opinions related to copays over at Evidence in Motion. I won't cut and paste what he states, but I will express my take on the issue.

Do not make excuses for a patient's insurance copay. If you think it's too expensive, then did they really need to be in to see you in the first place? If they need your services, then don't be afraid to let them know and provide them with that service.

Another issue in the area I work in is the difference in copay for a PT owned outpatient clinic vs. a hospital run outpatient clinic. Basically, the PT owned copay is high and the hospital has none. What does one do in this situation? Refer to the hospital to "save" the patient money? If so, then what does that say about your business and your beliefs about your clinical skills when you confirm to this patient that the clinic choice doesn't matter, only the cost (so choose the cheapest?).

In the end, if you are providing quality, outcome oriented, evidence-based treatment, then you should let that prospective patient know that and then give them their moneys worth for treatment without letting that high copay rule over you.

Labels: Copays, Direct access, Healthcare, insurance, physical therapy

Lost a patient today to the local hospital PT. Was it because the local hospital had more convenient hours? Better PT's? Closer to home? None of the above. UHC limits her visits to 20 a year with a $30 to come to our PT owned clinic; but the pt had no copay or limits going to the hospital PT.

Where is the equity in that? ACN is horrible enough, now preference is again being given to physicians. Show me the evidence that the hospitals are providing better care at comparable costs and I'll understand. My guess is UHC will be charged more over greater number of visits than coming to a PT owned clinic that emphasizes quality care and outcomes over the bottom line of the hospital.

Labels: Direct access, Healthcare, insurance, over-use

A Wall Street Journal article reports old docs think new docs (residents) aren't getting the education they need because their weekly work hours are limited to 80 hours a week. That's right, 80 hours. It's actually not that good. That's an average of 80 hours over two weeks. So one could work 100 one week and 60 the next and still be compliant.

Old docs will complain about new docs not being altruistic. What seems to be their definition of altruism? Not working 150+ hours a week like they did in their training. Seems reasonable, right? You have to do it because I did! Here are the "main" findings:

Eighty-seven percent of the doctors thought continuity of care had worsened, and 75% thought the physician-patient relationship had deteriorated.

Sixty-six percent said residents’ education had gotten worse, 73% said residents were less accountable to patients and 57% said residents’ ability to place patient needs above their own had declined.

Half thought residents’ well being improved. But 56% of the teaching faculty found teaching less satisfying.

I find it interesting that in a system in which residents are paid about 20% of the staff to cover nights, weekends, holidays and everything in between, that those in charge are complaining about being able to have less of the resident.

Teaching hospitals provide a great service to our country in terms of educating our future doctors. But don't think it is altruism on their part. They get 5 residents for the price of 1 staff and used to be able to work them at their whim (and bottom line). Now that there is a 'limit' of 80 hours (ha! again I say ha!) somehow it's a detriment to patients and resident education.

Finally, the 80 hours are constantly ignored and subtly understood that that is the way the game is played. Doctors now are being paid less (don't believe big insurance), for more with less kudos than when "old docs" had their training with patients paying cash, receiving gifts and not having to answer to anyone but themselves.


UPDATE: Great response over at Over!My!Med!Body giving a first hand med student perspective on the whole "you have to because we had to" residency issue. Please read. Well written and shows the other side of the coin.

Labels: AMA, Healthcare

David Colquhoun maintains a page on "Complementary and Alternative Medicine (CAM)". It is a worth while read. You can find his website here. Below is a fun argument about the dilemma of CAM treatments.

The dilemmas at the heart of 'alternative medicine'

All forms of ineffective treatment, 'alternative' or otherwise, pose real dilemmas that are usually neglected.

The definition dilemma

* Once any treatment is shown beyond doubt to be effective, it ceases to be 'alternative' and becomes just like any other part of medical knowledge. That means that 'alternative medicine' must consist entirely of unproven treatments.

The lying dilemma

* Suppose that a treatment owes all its effectiveness to the placebo effect, e,g. homeopathy (even Peter Fisher almost admitted as much). But in some people, at least, the placebo effect is quite real. It may be a genuine physical response, though one that does not depend in any activity of the drug, or other treatment.
* If the placebo effect is real, it would be wrong to deprive patients of them, if there is nothing more effective available. For example, if terminal cancer patients say they feel better after having their feet tickled by a 'reflexologist', why should they not have that small pleasure?
* If the foregoing argument is granted, then it follows that it would be our duty to maximise the placebo effect. In the absence of specific research, it seems reasonable to suppose that individuals who are susceptible to placebo effects, will get the best results if there treatment is surrounded by as much impressive mumbo jumbo as possible.
* This suggests that, in order to maximixe the placebo effect, it will be important to lie to the patient as much as possible, and certainly to disguise from them the fact that, for example, their homeopathic pill contains nothing but lactose.
* Therein lies the dilemma. The whole trend in medicine has been to be more open with the patient and to tell them the truth. To maximise the benefit of alternative medicine, it is necessary to lie to the patient as much as possible.

As if telling lies to patients were not enough, the dilemma has another aspect, which is also almost always overlooked. Who trains CAM practitioners? Are the trainers expected to tell their students the same lies? Certainly that is the normal practice at the moment. Consider some examples.
The training dilemma

* If feet tickling makes patients feel better, it might be thought necessary to hire professional feet ticklers who have been trained in 'reflexology'. But who does the training? It cannot be expected that a university will provide a course that preaches the mumbo jumbo of meridians, energy lines and so on.
* A good example is acupuncture. It is often stated that one of the best documented forms of 'alternative medicine' is acupuncture. Certainly the act of pushing needles into to your body elicits real physiological responses. But recent experiments suggest that it matters very little where the needles are inserted. There are no 'key' points: it is the pricking that does it. But its advocates try to 'explain' the effects, along these lines.
o "There are 14 major avenues of energy flowing through the body. These are known as meridians".
o The energy that moves through the meridians is called Qi.
o Think of Qi as "The Force". It is the energy that makes a clear distinction between life and death.
o Acupuncture needles are gently placed through the skin along various key points along the meridians. This helps rebalance the Qi so the body systems work harmoniously.
I suppose, to the uneducated, the language sounds a bit like that of physics. But it is not. The words have no discernable meaning whatsoever. They are pure gobbledygook. Can any serious university be expected to teach such nonsense as though the words meant something? Of course not. Well so you'd think, though a few 'universities' have fallen for this, to their eternal shame

Obviously it isn't always neccessary to wait for a treatment to be unequivocally proven before it's use. However, it's basis should at least be plausible.

Labels: CAM, EBM, Healthcare, tips

News that Massachusetts (to be referred to as Mass as I'm lucky to spell it correctly more than once) will now require it's citizens to have health insurance. I think this is significant as most people focus on health care improvement by formulating ways the government can provide more social insurance focused on health care. Now we have a state trying to solve uninsured by treating it like car insurance...it's simply something you must pay for.

This will be an interesting experiment. Success would likely lead to a flood of similar legislation through out the country.

I feel this is an excellent possible solution to the growing number of uninsured. I've always felt our health is our responsibility and we shouldn't blindly depend on the government to provide solutions for us.

Labels: Healthcare, insurance, legislation, reform