Humpty Dumpty

In the book Alice Through the Looking Glass, Humpty Dumpty pours scorn on word definitions. When challenged by Alice, he replies “When I use a word it means just what I choose it to mean—neither more nor less”.

I evaluated a Workman’s Comp patient with LBP last week (a pretty common occurrence in PT). The patient, who’s symptoms began 3 months prior, had already received 10-12 physical therapy treatments at the beginning of his episode without relief (don’t know what constituted the treatments). He had been referred to us for additional care after being evaluated by a spine surgeon (?!). The patient met 3/5 CPR criteria for lumbo-pelvic manipulation and had an initial favorable response based on pain and ROM findings following intervention (Childs et al, 2004). He was to see me twice the following week and then once a week for a couple of weeks after that if needed (our average number of visits for this type of patient is about 4.5 to complete a course of care).

Well, Humpty Dumpty called to me from his wall last week in the form of a physician reviewer who had reviewed this man’s case and denied further treatment. His review was based on the abbreviated report I had sent to the physician. All our progress notes sent to referring providers are written in a terse, no-fat fashion in which current response to treatment is graphically documented and in this case, had the citation of supporting evidence for the intervention being rendered as well as the probability of a 50% reduction in disability in 1 week (68% in this case).

His rationale? He stated that no objective findings warranted further intervention, that a passive treatment approach to his condition was not effective, cited an unreferenced, internal clinical practice guideline for care, and then proceeded to cite the Philadelphia Panels recommendations as his supporting evidence (despite the fact that the Philly Panel did not include studies utilizing manual physical therapy, which was the basis of this patient’s intervention (see comment by Flynn et al)). To top it off, the denial was following a phone conversation I had with him in which things seemed to be “it’s all good”. 

Amazingly, Humpty Dumpty interpreted physical therapy as “passive intervention”, despite my report to the contrary and “EBP” as selective quoting of whatever publication you are familiar supporting your point of view. Heck, if anything he should have denied care on the basis of the Assendelft Cochrane review to which I would have then needed to (and could have) legitimately respond.   

I understand that in many cases, intentional or not, therapists have practiced in a manner that is not effective or cost efficient. On the other hand, it does us no good and keeps our health care system from moving forward when payors and reviewers practice their craft with similar inefficiencies (which will ultimately drive cost up as well). 

Words mean things, so make sure you confront your Humpty Dumptys whoever they are. I guess “recovered” in this unfortunate patient's case means he had an opportunity to experience the health care system…..gee, I am sure he is better now! (at least Humpty Dumpty seems to think so).

 

Rob

Comments

[Selena Horner]

I know I shouldn't find any humor in your post, Rob, but I'm chuckling. I am so glad to hear that I'm not the only one that has headbutting issues with physicians or third party payors.

In your situation, he saw "manipulation" and the world stopped there. He probably didn't read your plan of care, didn't look at the results of the initial treatment and forgot that PT had already been attempted with no results. Red flag right there before there was any consideration of all the other variables that should have been considered. And I bet ya, he was downright proud of himself!

In situations like yours and the ones I get myself into, I wish I had classes in negotiating. My brother inlaw is a coporate attorney who does a lot of work with mergers and my husband and father inlaw are vice presidents in manufacturing companies - they have experience and have had classes in learning how to know what the other party really wants, asking for more than they intend to receive, not physically giving away what they themselves really want (using appropriate body language) and somehow making the party they are dealing with feel good about the final agreement. It's all a game.

The sad thing in your situation... PT was already attempted, the patient had seen a surgeon, bounced to you... well, I am going to assume that potentially the insurance company is going to cost themselves more money - we all know that the surgeons only have one fix for problems and the fix is never a cheap option. If the fix doesn't really address the actual reason for the original complaint, then the fix really doesn't "fix" the problem and the problem remains. The cost of 3-4 more visits versus the cost of potential surgery combined with the cost of potential further days off work combined with the cost of short-term or long term disability... hmmm? Combined with the psychosocial impact and a higher potential of becoming a patient with chronic pain.... uggh. Humpty Dumpty must have a money tree in his backyard.

[John Goodrich]

Rob, I would pay to go to a course on this issue. I have had a number of similar experiences. I recently got a call from a case manager who insisted I see a client x2-3/wk, even though it was not necessary, goals were being achieved, the patient had been complient and cooperative (she was ticked off that the patient took time off for Christmas). I try to be as up front with these people as possible, but I find it amazing how hard we have to work to actually save them money.

[Britt Smith]

rob,
Unfortunately, the case-worker or adjustor is only parroting whatever information they have in front of them. 'Evidence-based' anything is what evidence in culled from the literature (and subject to what biases and filters are a priori) and what interpretations are brought in final analysis. I'm sure this person is working from a script or algorhythm about what practices are 'standard' practice, an internal guideline (if you will) for the insurance company or HMO. It was probably developed by policy-makers and maybe consultants with an eye on cost-control and not necessarily effectiveness. As Selena points out, they probably don't see the big picture in relationship to surgery, injections, imaging etc, which carry much higher costs, in monies and morbidity.
In selecting their evidence, it is interesting that they dwelt on the Philadelphia Panel. You know, as well as anyone in the room, that the publication of Philadelphia Panel, which did some nifty work on 'clearing the weed from the garden' of what is effective in practice. However, it also posed the risk of the public or the policy-makers interpreting our practice as only limited to the scope of their systematic review [again, as you said, no review of manual therapy]. The great misfortune is that the payor is guided by a different set of tenets [values, biases and assumptions] than the providers. We are often at their mercy, or merciless action, in issues about what is reimbursed, and what they define as standards of OUR practice. You, as a manual therapist, are a minority in our profession, indeed, smaller minority as a Fellow of AAOMPT (<1% of all the PT population) and thus you are an 'outlier' to the insurance companies algorhythms. Until we demonstrate that PTs, AS A PROFESSIONAL GROUP, perform procedures, such as manipulation, for LBP with a level of frequency (appropriate for the condition, thank you) and level of proficiency, then we will have a difficult time arguing for these procedures as standards of practice, guideline status, etc....
Hmmm, I think the cap is back on for Medicare, also.
Britt

[David Penn]

Rob,

This is happening all over Texas now since the advent of the TDI-DWC took its stab at a failing workers comp system. The typical "Evidence" that is being practiced in Texas follows the internal criteria guidelines along with the Official Disability Guidelines and the American College of Occupational and Enviromental Medicine guidelines which latter two I know are consensus based. I have won a few battles similar to the one you speak of by providing the evidence to the people of influence that understand EBM in Austin,Tx. Call me and I will explain the elements that have been successful for us in East Texas.
I wonder if case series reports such as the recent one in JOSPT that Josh Cleland, et. al. wrote about on Cervical Radiculopathy treatment would hold up against these insurance giants.
I worked about 2 hours on a case (writing a rebutle letter to Dr. Tonn) about an injured worker that twister her knee at work ( 6 week old injury) that resulted in severe effussion, limited ROM, strength and inability to walk without an immobilizer. Her position was that she did not have an MRI report to determine if there was internal derangement of the knee. If so she was going to deny therapy. This line of thinking suggests that surgery is for every meniscal tear which is contrary to the literature. This simply drives up costs to the insurance company, employer, and increases the suffering to the patient. But there you have it, "Quasi-Evidence" in Slow Motion- pun intended.
The other disturbing fact is that many of these insurance companies view guidelines as policy when they were never intended to be applied to individual cases. What happens when new information comes out in the literature the refutes what the guidelines once supported? We have to be good at continually keep pace with the literature and citing these references as Rob did in his case of Humpty Dumpty- then you will be lucky to get your request reduced by only 50%. Remember, nobody twister my arm to become a physical therapist is what I keep telling myself.(LOL)

[Kris Tate]

Comments from the front desk:
I am not a therapist or a research geek, but I work for both. I want to tell you all a little about the work comp patient that Rob is referencing in this post. From the beginning: the patient is referred to us for PT by a spine surgeon. As you all are aware, work comp requires authorization before any treatment can occur. After the initial eval, I faxed the requested plan of care to the "medical reviewer" It progressed as Rob has outlined in his post. In the meantime, the patient is asking for an appointment. I have to tell him that his claim is denied- work comp will not pay for his treatment. Of course, he is confused and frustrated. The next day his wife calls and wants explanation. I try to explain but she interjects that for the first time since the accident, he feels better, has hope that he will not be in pain forever. What to do? We will make an appeal to Texas Work Comp Commission which will probably take months for review, but does that help our patient right now? Isn't that what we all strive to do- help our patients have the best quality of life pain free as possible? So right now there is a guy out there that the work comp system has failed miserably. He was hurt doing his job; he knows there is help out there, but no one wants to step up and pay for it.

[Britt Smith]

Kris,
Good to hear from the front desk, affectionately known as 'the trench' (as at the frontlines) in our neighborhood. You have the unique position of viewing all angles of this chaos we call a healthcare system. One comment on your position as clinic advocate and patient advocate: A good office person (personnel) is as valuable as any therapist in the clinic for the patient, the therapists, the business and health care as a whole. You are the public's first impression of the physical therapy environment. The ethos of the clinic is reflected in your compassion and your visceral response to the angst and anguish of the patients and their family trapped in a goofy system. Reassure them that Rob and the profession are working to improve this morass. Keep up the great work!
Happy New Year.
Britt

[Rob Wainner]

Great comments all.

It now looks like CMS has positioned itself to become the biggest denier of all. The only good thing is that they pose a visible target we can collectively focus on.

Rob