Improving Patient Value in Managing Aches and Pains (Part 2)

With the debate on how to reform the American healthcare system and how to contain medical costs, the pundits report the need for drastic measures which meet the reform objectives of aligning healthcare payment to providers with achieving demonstrably better outcomes.  The primary focus of the reform debates and policy provisions in the Affordable Care Act (Health Reform Law) has been on how we can improve the management of chronic disease (such as Diabetes, Heart Disease, Obesity, Arthritis) and eliminate or reduce unwarranted hospital errors through integration of health information technology and integration of care delivery. 

Basic logic would suggest that for successful reforms to occur you must also assess the cost drivers associated with care delivery and determine the value of these cost drivers.  That is, are the most expensive services providing the health care consumer and the third party payors commensurate return on their investment?  If not, then reform provisions must consider regulatory measures to align remuneration with the high value services that are effective and contribute to patient wellness, health, and reduced disability.  Aligning care delivery with effective treatment pathways ultimately yields greater value and a healthier community.  The current system and the proposed changes to Medicare fall well short of meeting these objectives, and in fact, are cutting the most valuable services that allow our seniors to remain active, remain mobile, and remain independent.

The US healthcare system is among the best at treating acute injury and disease, but it is among the lease effective and efficient at treating the sub-acute problems such as musculoskeletal disorders.  Treatment of pain complaints is the leading reason for medical visits today.  The most common cause of pain are musculoskeletal problems with low back pain being the most expensive and most prevalent.  The cost of treating low back pain alone is beginning to surpass the cost of treating all cancers.  The cost drivers associated with treating musculoskeletal problems stem from inconsistent and highly variable referral patterns among physicians, too many office visits from specialist to specialist, too many tests and imaging studies (strongly correlated with physician ownership of X-Ray, MRI, and CT Scans), which lead to inaccurate diagnosis, and unneeded surgery and endless prescription medications.

Medicare data illustrates that from 1996 to 2004 (risk adjusted), there was a 629% increase in expenditures for epidural steroid injections, 423% increase in opioids prescribed, a 307% increase in spinal fusions.  It is also noted that there is a direct correlation between MRI and CT rates and surgeries.  All of this increase in invasive treatment of musculoskeletal problems may be justified if patients quality of life and independence was preserved, however that isn’t the case.  In fact, the evidence paints much different picture.  Social Security disability statistics suggest that disability from musculoskeletal disorders is rising not falling—from 20.6% to 25.4% in 2005. 

When the evidence is considered, it is clear that we perform too many surgeries, we prescribe and consume too many medications, and we aren’t getting healthier as a result--in fact, the opposite is true.  What’s more is that there is a wealth of high level research which clearly demonstrates a much more efficient paradigm for managing musculoskeletal disorders which includes more management and oversight by a physical therapist.  When physical therapists are included in triaging musculoskeletal disorders through collaboration with physicians and non-physician practitioners (such as physician assistances and nurse practitioners) as well as patient self-referral scenarios better outcomes are achieved that are more cost-effective when compared to the current traditional medical model of management.  Many countries, including Australia, United Kingdom, Netherlands, New Zealand, several providences in Canada, the US Army, some Veterans Affairs (VA) and Kaiser-Permanente hospitals, several workers’ comp models, and the Virginia Mason Hospital System all employ successful PT triage models.  These models remain viable today and have expanded in recent years due to their success at improving outcomes with great value and patient satisfaction.  What’s more, the medical research suggests that only a small percentage of patients who would benefit from being examined and treated by a physical therapist make their way to seeing a physical therapists.  (More on the value of patient self-referral to Physical Therapy-- Here).   

If better access to PT would result in better outcomes at lower costs, why hasn’t there been a massive overhaul from the traditional medical model?  The answer is simple—The Medical Industrial Complex and physician control of profit streams based on referral powers.  The amount of dollars passing from medical device and pharmaceutical industries to physician groups is astonishing, and this fuels political special interest groups which fortifies the status quo.  In addition to the economic forces evident from the ‘medical industrial complex’ there are additional profits from referral arrangements where surgeons have a financial stake in imaging companies, specialty hospitals, and physical therapy clinics.  These arrangements are shown to clearly impact referral and utilization patterns.  The impact of these profits from referral arrangements has been astutely documented in the June MedPAC report to congress found HERE.  The real victims are the health care consumers who continue to give credence to the halo above their physician’s head who fail to disclose their financial interest in the entity being referred.

Also, insurance payment policy for physical therapy are consistently being reduced, capped, or limited.  The most imminent example is with Medicare.  Every year since the Balance Budget Act of 1997, Congress has had to act to eliminate or offer an exceptions process to avoid arbitrary monetary caps to the out-patient therapy benefit (Physical Therapy, Occupational Therapy, and Speech Language Pathology) under Medicare.  This year the saga continues, and Congress must act again to assure that therapist have a means to over-ride the therapy cap when medically necessary services are required.  With the therapy cap, anyone requiring services beyond the $1870 monetary cap (set for CY 2011) will be responsible for the total cost or seek these services in a hospital based department.  The Medicare beneficiaries who experience stroke, hip fractures, diabetes, osteoporosis, neurological disease, arthritis, cardio-pulmonary disease or who have multiple injuries in a calendar year are particularly at risk for requiring the skilled services of rehab professionals beyond the coverage limitation. 

In addition to the arbitrary therapy caps in 2011, physical therapy services are seeing a cut in reimbursement for the services we provide.  On average all out-patient therapy services will see between 4-6% reductions in payment.

These reimbursement cuts paired with the therapy cap significantly erode the ability of physical therapists to meet the needs of our patients while achieving financial equilibrium.  When the Medicare beneficiary is competing for limited schedule space with the best physical therapist in town, it may be difficult to justify scheduling the Medicare beneficiary whose payor will be paying less and requiring more administrative oversight.  This simply will reduce access to the evidence-based and cost effective alternative that physical therapists provide versus the status quo of more medication, more imaging, more office visits, and more surgery. 

One of the main tenets of health care reform is to improve access to quality health services with a focus on prevention, wellness, and value.  By reducing payment and reducing access to the one group of health care professionals whose entire existence is to reduce impairments, disability and pain by non-invasive, non- surgical means we are weakening the very intent of the reforms. 

Please contact your legislators and ask them to support legislation that eliminates the therapy cap and extends provisions which improve access to therapy services.  An advocacy link for patients can be accessed HERE to assist with contacting your Senator and Representative.  Also consider exploring the Coalition for Patient Rights at http://www.patientsrightscoalition.org/  for more information about how you can help in assuring you have access to quality primary care services which are patient-centered and evidence based.

Dr. Jason Richardson, PT, DPT, OCS, COMT

Twitter @TNBackPain

www.resultsphysiotherapy.com