Evidence Based Rehab

The Insurance Journal released an article discussing how a "surprising" share of work comp case costs come from unanticipated costs or, as they term it, "Adverse Surprise Costs." The study reported on was said to find:

Adverse surprise cases were disproportionately chronic conditions with multiple surgeries. They were also disproportionately back pain cases.

That's no surprise to me, however, and should really not be a surprise to anyone dealing with chronic pain and low back injuries. While back pain is not the only musculoskeletal condition being over-treated with narcotics, expensive imaging, and surgery, it certainly is the most costly of all. In fact, most of my recent posts have centered around this subject (you can find them here, here, and here).

What is surprising is that, despite all this research showing all this imaging, surgery, and narcotic prescription make things worse often, we are still using that recipe to treat most folks with LBP. In fact, those doing it are being the ones rewarded with reimbursement for doing so.

Jason L. Harris

Labels: evidence based medicine, insurance, LBP, Low back pain, over-use

Reading the newest issue of Orthopaedic Physical Therapy Practice (the magazine of the Orthopaedic Section of the APTA) I found interesting the Editor's Message written by Christopher Hughes, PT, PhD, OCS. The letter titled "When All Else Fails...We Succeed!" relates that an episode of care from a Physical Therapist that does not end with hoped for gaols met, is not a waste. That, in fact, it is a valuable tool to help in the clinical decision making by MD's - especially in the arena of deciding on surgery or other invasive procedure.

I agree with this view, and have educated a number of my clients that at the very least, their episode with me will make them better prepared for surgery and increase their prognosis after surgery. I would like to speak on a subject related to this: Over Utilization.

I will give our fellow professionals the benefit of the doubt and say that the desire to achieve all goals for all clients leads to continuing treatment past maximum medical benefit. We all do this, and looking at my stats from 2008, those who were discharged w/o all goals met averaged about 2-3 more visits than those who where discharged with goals met. Some of that is related to me trying to get that last goal or two, some related to MD referring back to "just try a little more", and more is related to the client wanting to have more PT. Now, what we need to be aware of is "benefit chasing".

We all know of clinics/PTs that do this. If the client has 20 visits per year, that's how many PT sessions they'll get. Regardless if it's a knee sprain or s/p ACL reconstruction. It's this practice behavior that really hurts us, particularly in the eyes of the insurance companies.

I'm sure there are many reasons why this practice occurs. Including desire to maximize profits. What we need to do as a profession is self police and encourage appropriate utilization of our care provided. Steps we (individually) can do are:

1. Set goals with time frames, and share these with our clients. This will help hold ourselves accountable.
2. Use outcome surveys. DASH, Oswestry, Neck Disability Inex, etc. Easy to get caught up in the "I feel a little better" trap and keep treating. Use these tools to help measure actual perceived change allowing you to make better continued treatment decisions.
3. Track your outcomes. This will allow you to evaluate your tendacies in treatment and areas you can improve.
4. Question your collegues and be open to constructive critisism from your collegues regarding visits.

How do you monitor utlization? Do have anecdotes regarding over use or proper use of PT sessions? Any other suggestions on how to prevent over utilization?

Labels: evidence based medicine, outcomes, over-use, 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

In this Wall Street Journal article, the issue of excessive imaging and surgeries for back pain is discussed. As PT's we have all seen the patients that have had x-rays and MRI's for simple non-traumatic back pain and wondered 'Why were these done'. The article lists common missteps doctors make when treating back pain:

• Over-prescribe epidural steroids.
• Order excessive imaging
• Perform invasive surgery too soon.
• Fail to educate patients about surgery and alternatives to surgery.
• Fail to assess mental health.

Why do doctors do this? Physicians are very smart and good at what they do; but, they are human just like us. Fear of litigation, pressure to please the patient, and just not knowing a better way are all plausible answers. The problem is, there are studies that show unneeded imaging can lead to diminished outcomes, and lumbar fusion surgery offers negligible benefits at best for the majority of the back pain population for the risks involved.

The program is spearheaded by the National Committee for Quality Assurance and strives to reward physicians that follow the plan and to educate the public about their options besides surgery. They produced a list of 16 guidelines for MD's to follow with a few listed below.

RIGHT CARE FOR ACHING BACKS

A new program is urging doctors to follow 16 guidelines including:

• Help patients quit smoking
Smokers with back pain have more severe symptoms that last longer and have poorer outcomes after spinal surgery.

• Encourage patients to maintain normal activities and avoid bed rest
Bed rest can lead to problems such as joint stiffness, muscle wasting, loss of bonemineral density and pressure sores.

• Use X-rays and CT scans only when appropriate
Unnecessary for first six weeks after onset of pain unless there is indication of a more serious disorder.

• Use epidural steroid injections only when necessary
Not recommended unless symptoms include radiating pain (sciatica, herniated disc).

• Hold off on surgery
Not recommended in first six weeks of pain onset; half of patients with radiating low back pain recover spontaneously.

Conservative care and education should lead to improved outcomes and lower costs in treating back pain in this country.

Labels: Low back pain, over-use, physical therapy, surgery

A nice story from MSNBC that points out what many of us in the health professions have believed for years. We pay more for less that other countries. While the article subtly attempts to link it to lack of universal health care, I feel it's more related to consumer (that's right consumer not patient) attitudes, laws that limit efficient choice of health care providers, and our for-profit insurance structure.

As we feel we are no longer patients but consumers of health care, we demand the best, demand it now, and demand to pay very little for it (for those with insurance). Unfortunately, these three are mutually exclusive. We have to give on one to receive the other two. We tried for many years to ignore that and operate like we could get away with it. Now, we are seeing the consequences. Insurance rates rising, health costs rising, and benefits being cut back. Universal health care won't fix this problem.

Personally, another bottleneck and source of increased health care costs is our inability to access rehab services with out a physicians ok. Often times this results in at least to unnecessary office visits to a practitioner with less musculoskeletal knowledge then the PT, and delayed care.

Finally, insurance providers are out to make money. Plain and simple. And with out proper regulation, they will continue to work together (when we can't do the same to oppose them) to drive down their costs. This includes increasing premiums, deductibles and co-pays while simultaneously decreasing what they pay to practitioners and what they will actually cover.

What is the answer? We as consumers need to take responsibility for what services we demand (not, well insurance will pay for it so just do it), and also require that our insurance companies incorporate our needs into figuring their bottom line.

Labels: insurance, over-use, physical therapy