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Grandpa Was Right

Shortly after graduating from PT school (1985), I remember telling my Grandpa that he needed to go get checked for an ailment he was complaining about. He told me with great sincerity “Rob, going to the doctor can be hazardous to your health!” I have often regarded his statement stemming from his being born in 1915, a time when being treated by a physician often meant you had a 50/50 chance of being better off because of it. However, as the years have gone by I am more and more convinced that his statement is a lot more applicable today than I once thought and these recent publications indicate why.

Although the results of two recent studies examining the practice patterns and beliefs of orthopedic surgeons and family practitioners were not totally surprising, it still takes one back a bit and reminds us of the significant potential role that PTs could have in the management of LBP and the enormous savings in both costs and suffering that could be realized. These two publications yank some pants down in a major way for all to see that orthopedic surgeons and general practitioners in Australia or Israel are wearing neither boxers nor briefs when it comes to the management of LBP.

Title: Orthopaedists' and Family Practitioners' Knowledge of Simple Low Back Pain Management (Finestone AS et al Spine. 2009;24:1600-1603)

"Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs. Significantly less importance was attributed to patient encouragement and reassurance by the orthopaedists as compared with family physicians.'

Conclusion: "Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice."

Link to the abstract: http://journals.lww.com/spinejournal/Abstract/2009/07010/Orthopaedists__and_Family_Practitioners__Knowledge.14.aspx

OK, those are the results from just one study. Fair enough. However, similar shortcomings were found in this study of over 3000 general practitioners in Australia with one important exception: physicians with a special interest in low back pain were MORE likely to believe that complete bedrest and lumbar radiographs are useful in the acute management of LBP and associated with poor patient management.

Title: Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain. (Buchbinder R et al Spine. 2009;24:1218-1226)

Conclusion: “A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community”.

Links to the abstract:

http://www.ncbi.nlm.nih.gov/pubmed/19407674?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

I wonder what the results would be if these two studies were replicated in the United States? I also wonder what the results would be if a similar study was conducted involving physical therapists’ beliefs and practices with regard to current best evidence in the management of acute and chronic LBP. Are we confident we would be proud of the results or left with our face a dark, beet-red color?

Well, the good news is that there is plenty of opportunity to fill a void by working to ensure members of our profession are utilizing current best evidence in the care of LBP and marketing ourselves as the Best First Choice for patients with LBP (not to mention non-operative musculoskeletal problems as a whole). The results on our health care system from that one area alone would ensure us a welcomed place at the health care table. How about moving forward with that?

It isn’t because we don’t have evidence related to the management of LBP that, when implemented, results in better outcomes than the passage of time or other comparative treatments. Rather, we simply don’t implement the evidence we have available.

This non-sense simply has to change….and soon.  Carrot, stick, or some combination of both, whatever it takes.

Rob

Happy 4th of July From EIM!!!!

All of us in this great country have so much to be thankful for that we actually need to take the time and, well......be thankful!! 

It has been over a year now that my daughter has returned safely from a tour of duty in Iraq.  In addition, many students that I had to privilege of training over the years as well as colleagues and good friends have been "over and back" also (BTW....Welcome Home Deydre Teyhen!!!).  Unfortunately, that is not always the case. Such is the price of Freedom and Liberty and it is these noble sacrifices that remind us that Free isn't "free".

 

I am definitely going to take the opportunity to fire-up my grill this weekend and partake of the wonderful 4th of July activities that we in the good 'ol USA enjoy.  However, I will also be spending some time reflecting and being thankful for the many things that are precious to me personally and to us as Americans corporately. I encourage you to do the same you begin to prepare to enjoy this special weekend. 

Although it is July 3rd today, all of your friends at EIM want to wish you a Happy 4th of July!

Rob

CMS Proposal for Policy and Payment Change in 2010

What do these potential changes mean for PT?  I haven’t a clue-do you?

Some of my takes:

-we are still looking at a 21.5% reduction in 2010 but it might actually be more given the “redistribution” in codes which have to be balanced. This might mean that it could be a more draconian cut than 21.5.  On the other hand, we have been exposed to supposed cuts since 2002 and yet a reprieve has always occurred.  The whole SGR has faulty premises acknowledged by almost everybody and in the context of bigger reform, I would have a hard time believing that something won’t change

-looks like specialists won’t be getting bigger bucks for “consultation” and will have to take the E&M route and this reduction will increase primary care type of payments by 6 to 8%.  (note for file:  check again why PT’s are one of about 3 practitioners left that cannot bill using E&M)

-in what might be the most crafty strategy that I have ever seen CMS devise, they are going after referral for profit imaging by decreasing payments and wanting outside accrediting bodies to credential imaging services!  There are other regulation suggestions on this 2 part initiative and MedPAC and GAO have obviously substantial data that suggests overutlization of these hi cost drivers.  The big question for us as PT’s-why can’t they extend this same philosophy for other conflict of interest scenarios like physical therapy centers?  Could an MD owned PT clinic withstand even rehab agency survey yet alone something more onerous like CARF? (note for file:  find out why our national association doesn’t list this as a hi priority for their healthcare reform position)

-PQRI, the voluntary reimbursement cut that almost nobody is doing is going to expand the number of measures and seek the ability to utilize systems contained within an EMR in an effort to streamline efficiency

While this is not an exhaustive list, these appear to be the major points of the proposal.  keep in mind that it must go thru comment periods and will undoubtedly have major changes in it prior to implementation at some level in 2010. Likewise, while all this is occurring, the national debate and potential massive reform legislation continues.

larry@physicaltherapist.com

A Rally For a Better Strategy-Questions, Questions

While only 603 participated in a virtual healthcare rally done by APTA, it is certainly a good start and a unique way to get the troops corraled.  It is also laudable that the collaterals and position of PT perspective in healthcare reform have been published. Unfortunately, they provide as much excitement as the fine print on a mattress tag.

We have documented in the past that what is missing from these efforts is the advocating for the wrong audience.  Reform is supposed to be about addressing societal needs. 

While I acknowledge that I have more questions than solutions for these complicated issues,let’s get some strategic thinkers, marketing experts, and PR folks engaged in the content development and it's presentation.  As PT's, we can’t hang our hat on a host of legislative success in recent years-particularly the big issues like direct access in medicare which is going on approx 10 years and the eliminating the medicare cap which has probably been around longer than fax machines. So how about a different approach?

Some questions:

Why instead of writing in language clearly meant for lobbyists and healthcare wonks don’t we write something that every American can understand and something that resonates with the day to day patient care lives of PT’s?

Why is wellness and prevention the highlight and apparently the priority?  How many PT’s actually do the example cited in the document of “for patients who are obese, physical therapists develop programs that can balance the progression of exercises with the need for joint protection and safety”?

How about how PT’s can help the approx 50 million without insurance by being used in the much needed role of musculoskeletal evaluator and extender of care for primary care physicians? Why shouldn’t we use great examples like US military system, sports medicine, and many employers models where PT’s are the front line?  Aren't PT's capable of assisting in the innovative solutions like this Fast Company article points out about Walgreens?

What about supporting policy that addresses a principle driver of healthcare costs-notably conflict of interest that is well documented and highlighted in current discussions on healthcare regarding imaging but there is seldom a mention of PT and other over utlilizers like DME and surgical centers?  We could provide well documented examples and although it is far too late, provide funding for research in this area (note to Foundation for Physical Therapy-very disappointed in the lack of funding i after raising money for this clearly identified high priority effort only to have it put back on the backburner where it will undoubtedly be too little too late).

The mention of comparative effectiveness research is great but please bring it to life.  What about the utilization rates in spine surgery and the cost effectiveness of physical therapy interventions for LBP and knee osteoarthritis?  Perhaps a few testimonials?  Can we find a consultant who writes informercials?

Why even mention PQRI?  It’s adoption rate by PT’s is dismal and the program is a reimbursement cut for any of the disgruntled that are participating.

I sincerely hope there is a next rally-with materials and a strategy that is exciting and can create exponential numbers of PT’s carrying the banner of being part of the solution to healthcare by understanding the needs of the real stakeholders-the millions of those that are without insurance and the hi costs to those that provide insurance to their employees.

Thoughts?

larry@physicaltherapist.com

A New Poster Child(s)

Farah Fawcett was a complex individual who shared a very public account of the high and lows of her battle with cancer up until her death this week.  For many of us (that are old enough) we vividly recall 1976 Life magazine image of Farah which would eventually sell more than 12 million copies and become the best-selling poster of all time.  As I was sipping my coffee this morning I wondered "could there ever be another Texan that had the hair and smile" that could ignite a generation of style and fantasy.  Fortunately the Foundation for Physical Therapy Special Edition Calendar arrived in my mailbox today.  If the June Poster Child(s) is not the next Texas icon and trend setter I will be utterly floored.  Please give generously to the Foundation and make a difference!

Tim

Health Care Reform and Physical Therapists

When I hear "rally," I immediately envision "rally caps" and baseball and the hope and excitement of a cohesive team coming from behind to win the game.

So, okay, what I envision when I hear "rally" is very, very different than a "virtual rally."

This evening the American Physical Therapy Association hosted a "virtual rally" to help physical therapists make an impact on health care reform.

By October 31, 2009 President Obama wants a bill on his desk for him to sign.  He's waiting for a health care reform bill that takes into consideration his suggested 8 principles.

Do you wonder how the American Physical Therapy Association is representing physical therapists?  The APTA's perspective isn't a secret.  That page doesn't have too many details, but this paper on the Role of the Physical Therapist in Health Care Reform is a bit more detailed.

The APTA panel did an excellent job disseminating current information.  The rally could have been much better with less time disseminating information and more time entertaining questions and energizing participants.  Maybe my problem was I wasn't wearing my "rally cap?"   Maybe the real issue is that a "virtual rally" isn't the time or place for "rally caps?"

Every one of us needs to put on our rally caps because we have a role and we need to have our voices heard.  First, we need to stay current and pay attention to all the various proposed changes that will be discussed and debated in about 6 weeks.  The APTA created a Health Care Reform resources center updated with current information and podcasts.  It isn't enough to just read and stay current, the next step is to get involved.  Members can use the Legislative Action Center within the above link.  Nonmembers and consumers can use the Patient Action Center to become involved and have their voices heard.

Now is "rally cap" time... put them on... choose to let your voice be heard!

photo by sportsstan via Flickr

~Selena

Physical Therapists and Moving Forward

What's beer got to do with it?  A lot. 

Michigan Brewing Company does it right.  Greater success and growth happens the more you rely or network with others.  This company is an excellent example of how creating beer can be so much more than creating beer.  This company has embedded itself in the community and win-win relationships have occurred.  At the same time, this company also forged a relationship with an individual who was instrumental in changing Michigan law.  The change is better from a business perspective for this company and others like it.

As physical therapists "Move Forward," who have we networked with?  Who do we have win-win relationships with?  Are we moving forward alone in hopes for success?  Should we have fear in creating a foundation of moving forward WITH others with similar agendas?

What about nurse practitioners...  here is an opportunity for some mutual networking where together a better solution occurs:

During their “Raise the Voice” campaign, the American Academy of Nursing (AAN) stated that the role of community-based nurses should be reexamined during the healthcare reform debate, given the growing shortage of primary care physicians across the country. According to Tine Hansen-Turton, CEO of the National Nursing Centers Consortium (Philadelphia), “Now may be the time to "think outside the box" and increase reliance on non-physician groups and physician assistants and expand to non-traditional settings such as nurse-managed health centers and convenient care clinics.” HealthLeaders Media reports that 85,000 nurse practitioners – of about 145,000 – are currently providing primary care and that NPs are one of the fastest growing groups of primary care professionals nationwide. Donna Shalala, former HHS Secretary and a speaker for AAN's “Raise the Voice” campaign, noted that more recognition is needed for the role that NPs play in expanding access and providing primary care. She stated that nurses “need a seat at the table” during healthcare reform debates and additional federal funding for nurse-managed health centers. (Simmons, Janice. Group Says Community-Based Nursing Model Could Boost Primary Care Coverage, HealthLeaders Media, May 11, 2009)

We are an "outside the box" potential and we are a non-physician group.  Wouldn't they love to have us on board WITH them?  What are your thoughts?

Cheers!

~Selena

Random Thoughts About Healthcare

Since healthcare will undoubtedly be in the news for the next several weeks, I thought I would list some random thoughts.

-healthcare, medical care, and health insurance are 3 different concerns with some overlap between them.  When those that bad mouth our medical care site the decrease in life expectancy of US and other “health” measures, they clearly don’t know the difference.  Attempts to solve all 3 at once thru one sweeping legislative is a little naive in my opinion.

-while I can find a lot of valid arguments against a gov’t run single payors system, the oft cited “we don’t want beaurocrats making medical decisions” shouldn’t be one of them.  We already have that with every major private payor in the U.S. 

-I don’t understand the logical deduction that many are making when they state “comparative effectiveness means rationing of healthcare”.  If we don’t have some analysis, we might continue to have some chiro’s continuing to treat kids for bed wetting.

-The idea of mandating employer coverage for health insurance is completely unfounded. When are we going to realize that the employer model of health insurance hasn’t worked and won’t work as business challenges are daunting enough.  Employer model has been around for a long time and has essentially made big companies financially vulnerable and contributes significantly to increased cost of products/services and lack of companies being able to expand.  The vast majority of new jobs are created by small business-mandating insurance coverage might stop a new business in its tracks before it starts.

-There is plenty of money in the system to take on the 50 million without coverage but there isn’t enough providers.  Therefore, without force multipliers and deregulation around those that can provide services, there will be long lines and general angst.  The military healthcare system has been dealing with these issues for years and its system should strongly be considered as a model.

-given the hi percent of GDP on medical care, I do believe that a catastrophic health benefit should be a birthright and affordable primary care should be available.  The one thing you can say about medical care-even at its worst-there are true economic transactions and people performing services which is good for the economy as those employed do pay taxes (will avoid commentary about the failed bank crises and their number of employees by comparison).

-You can’t have healthcare reform without legal reform and business reform.  Significant cost drivers include “defensive” medicine and fee for service in “conflict of interest” business arrangements. The hidden cost of regulation contributes to to the problem.

-Consumers already exhibit a strong voice in their care.  Per FDA data, 70% of the time a patient requests a certain type of drug from their doc, they get it.  The idea that individuals can make complicated decisions about spending their dollars makes no sense at all.  Increased co-pays have not solved the problem and in many cases are counter-productive towards savings.

-There are generational differences in medical care. Older baby boomers generally trust their doc, younger generations are skeptical about their medical providers and they are comfortable doing searches on the internet to help them determine their best care.  They also want a CNET style of healthcare which will show them number of choices, lowest cost, and provider ratings. 

-Anybody who believes the gov’t knows how to implement “quality standards” ought to read about the adoption rate of PQRI by MD’s and PT’s.

-Not sure I understand why we aren’t looking at the success of mandating individual auto insurance as a model. This substantially opened the market to individual underwriting and competition which is something we don’t have in the health insurance marketplace.  Many employers would be happy allocating to an individual an amount of money for them to choose their own policy outside of their employer.

Thoughts?

larry@physicaltherapist.com

The 6th Vital Sign?

There just might be a race to define the 6th vital sign.  Field of specialty, for the moment, seems to be a variable that will create difficulty in defining the 6th vital sign.  What will be the 6th vital sign?

Unfortunately, the 6th vital sign I am going to mention doesn't appear in Wikipedia.  Last year at the Annual APTA meeting, Pamela Duncan, PT suggested walking speed be the 6th vital sign.  Recently a White Paper written by Stacy Fritz, PT and Michelle Lusardi, PT was published to raise the awareness and allow for discussion of self-selected walking speed to be the 6th vital sign.  The work that has been done on walking speed is quite interesting and vast: data suggests whether a person is dependent or independent, if the person has a likelihood of being hospitalized, if the person should be discharged to a skilled nursing facility or home, whether the person has a potential to fall or not to fall, and defining categories of how well the person is able to walk.

Body temperature... heart rate... blood pressure... respiratory rate... pain... and... ??  Are we ready for the 6th?  Do you think walking speed should be a measured vital sign?  Is the data strong enough to identify walking speed as the 6th vital sign?  Will this vital sign just be something to document OR can we alter this vital sign with our services and alter someone's life?

photo by Michael Brooking Photography via Flickr

~Selena

EIM Receives Small Business Award!!

EIM won the 2009 Greater Louisville Inc. (GLI) Inc.credible Award for an outstanding small business. This award plays tribute to the top small businesses in the Louisville, KY area and EIM received the award for businesses with 10-49 employees. Nominated businesses were judged on the following criteria: community involvement, growth in employment, number of years in business, financial performance, innovativeness of product/service, and response to adversity. EIM was selected specifically for its flexible workplace model that has allowed for inc.credible talent attraction and cultivation. In recognition of EIM’s accomplishments, GLI states in their announcement that “EIM has created a genuinely unique on-line/on-site, best practice marketplace (an ‘educational-studio’) for the advancement of musculoskeletal physical therapy practice, incorporating a variety of educational strategies in a coordinated fashion, including; weekend courses, on-line courses, topical discussion threads, on-line journal clubs, and residency and fellowship degree tracks.” GLI went on to state, ”What makes EIM special is their founders and professional faculty. While administrative services are centralized, their network of subject matter experts (faculty/instructors/authors) reside throughout the US and occasionally beyond national borders. These experts would not be able to closely collaborate if required to reside in single or limited geographic location. Keeping this virtual office in mind, EIM developed and launched the first (and at this time, only) distance-leaning based residency and fellowship education model for physical therapists.” Thanks to everyone that has contributed to EIM’s success! Visit GLI’s website for more information.