We Are Still Not Listening

Wong and colleagues make the case in this recent survey on therapeutic ultrasound published in PTJ that clinical expertise is useful for guiding decision-making in the absence of higher levels of evidence. Although this is certainly true, it doesn't readily apply in the case of therapeutic ultrasound as traditionally used by physical therapists. Repeated studies (including Cochrane reviews on using ultrasound for virtually every musculoskeletal condition managed by physical therapists) have failed to find a benefit for therapeutic ultrasound. These reviews also do not appear to offer a glimmer of a hope that even a small subgroup exists for whom therapeutic ultrasound is beneficial.

I would offer a much more simple explanation for the reason that therapeutic ultrasound continues to be so widely used...it's the same old 15- to 20-year "evidence gap" and excessive practice variation problem that exists throughout our broken health care system (ie, we practice like we're trained in our initial professional training, regardless of even overwhelming evidence to the contrary) and the fact that third-party payers continue to reimburse for mostly worthless interventions such as therapeutic ultrasound. In our fee-for-service health care system that rewards doing procedures absent of any regard for whether the patient actually benefits, I am not an optimist that much will change. Surveys like this cause Dr. Delitto's words that "we are still not listening" to ring loudly in my ears.

John

Comments

[Selena Horner]

There are greater and greater pressures for physical therapists to be "productive." Productivity is generally measured on the number of units billed per visit (often times with no thought as to the monetary value of the units billed). Sometimes, to meet the productivity requirements some units billed (ultrasound included) are easily delegated to inappropriate staff to generate the units. If a department allows an aide or a tech to provide services for the PT and the PT is capturing the provided service as part of the PT's productivity, there will continue to be overutilization of certain procedures.

Maybe it isn't just a fee schedule or an evidence gap issue... could just be the pressures of how management measures productivity. It's an aspect of the game we play to stay employed.

Would physical therapists change and provide less passive modalities if performance was measured on outcomes? And, what if productivity wasn't measured on average units per visit, but instead on time spent with patients that was reimbursed versus time not treating patients? OR what if productivity was measured on average dollars reimbursed per visit combined with clinical outcomes?

[Jim Cenova]

It's amazing to me that the Delitto editorial was written almost ten years ago, and as you have pointed out little has changed in practice patterns. We certainly are a profession that is divided. We can't agree whether RFP is a good or bad thing for the profession, whether or not Ultrasound is a beneficial intervention, whether billing for something which is questionably beneficial is borderline fraudulent, etc. Certainly seems like we are a profession in need of serious direction.

Here's to hoping that comes from the top at APTA.

btw, all of my points, I think, have obvious answers. Well. obvious to me, but certainly not to all on this board.

[Laura OConnor]

I cannot speak for anyone else, but I know that many of my patients ask for ultrasound because they have had it before, and we all know the strength of the "placebo effect." And I would agree with the productivity comment. That is not the case where I am employed currently, but it has been in the past.

[Matt Lazinski]

I think that overall the community loves to speak about this issue, but does nothing about it at their own level. I took the OCS exam in 2007, and when I received the results I was disheartened to see that the content areas of evidenced based practice and critical inquiry were #6 and 7 out of 8 content areas in terms of correct answers (1 and 2 for myself, thanks EIM!) These are obviously people that are trying to expand on their knowledge, but still are still not on board with advancing the profession.

[John Ware]

Matt's got a good point that each of us is not doing enough in our own little world to advance EBP and results-based PT. I think we have gotten so busy with battling reimbursement issues with Medicare (learning how to "game" the system), RFP (scape-goating the docs), and various turf battles and legal struggles (chiros and direct access), that we have forgotten that what it's really about is getting pt's better in the most effective way (EBP).

Are we still a patient-centered profession, or are we letting our collective ego take over?

I think we should move towards "tending our garden" with more care and concern. I agree with John C., though, that we need to better define and communicate what it is we're trying to "grow".
John

[sean]

John (Ware),
I think I want to disagree with you about PT's using docs as scapegoats in regards to RFP. But I would like to read exactly what you are implying in that statement.
I feel that arguing against RFP is more an issue of our political and lobbying systems gone awry. In most cases, a physician is not qualified to run a PT clinic and charge the services as incident to.

[sean]

A few years ago I stumbled upon the (anectdotal) effectiveness of US-Estim combo on acute and chronic, posterior neck muscle-guarding. I tried a quick pub-med search but apparently couldn't find the correct key words.
Have there been any good studies on this modality? I find that in the patient who complains of worse pain, as a result of simple movements and/or light palpation, this is an effective treatment.
I truly cannot remember the last time a normal US was performed in our clinic, and we probably perform less than 100 combo treatments a year, in total.
I will also admit that this is not an effective treatment for the 10+ hour/day computer worker. Is there any evidence out there for/against this treatment, in my selected population? Or am I going to have to continue practicing this treatment utilizing my own pseudo-CPM?

[sean]

I left out an important detail. We utilize this treatment with an eye on transitioning to mobilizations and ther-ex to help the patient achieve goals. It is not a full treatment plan for anyone unless they cannot tolerate movement/mobilization. In that case, the patient is not progressing, and he/she is referred back to the physician for re-examination.

[Bill Koch]

I too echo what Matt said above. I have been following EIM for several years and recently registered for the OCS exam for 2008. I was somewhat frustrated when I received the registration confirmation packet and surveyed the sample test questions. The correct answer to one of the test questions as listed was to treat the patient (I believe it was a knee injury) with pulsed US to decrease soft tissue inflammation. Maybe that is part of the reason why 80%+ of OCS use US in practice.

[John Ware]

Sean,
I may be psychoanalyzing a bit too much, but I would say that our collective feelings of inferiority are manifested in a tendency to blame POPTS for much of our business growth/revenue problems. I think the inferiority complex is actually fueled by a reimbursement system that does not reward superior results.

It's very frustrating and demoralizing for private practice PTs to know they're doing a better job of diagnosing and treating pts, but still having to scrape for pennies from 3rd party payers, continually wrangle with Medicare for more visits and a fair fee schedule and suck up to physicians for more and more referrals in order to increase volume.

The RFP docs are an easy target, and take the focus off of ourselves and what we have real control over: how we practice.

I think the RFP issue has devolved to a lot of griping, notwhithstanding recent legal developments in SC. I'm not going to wait for some judge to level the playing field for me. I can't hold my breath that long.
John

[sean]

John,
I think you are responding in the wrong thread to one of my posts. did you mean to respond in the RFP thread?

[John Ware]

Sean,
The thread started on the theme that PTs are not using EBP, as illustrated by the Wong et al article on US use by OCS's. John C. also referred to the fee for service nature of our reimbursement system, which does not take into account actual benefit to the patient.

My comment was that RFP, among other things, has distracted us from what I think should be our primary focus-results for our patients. You said you didn't agree with me on that, and then seemed to ask for an explanation, so I provided one.

The common "thread" here is EBP, or in this case, the fact that so many PTs seem to go out of their way to ignore it.
John

[sean]

John,
I see where you're coming from. I agree that EBP should be our main focus. But we need to temper that with the facts that other disciplines are trying to legislate us out of existence; docs are trying to maximize their profits with RFP; and insurance companies are slashing rates. If we do not pay enough attention to these, we will not have to worry about EBP.
I agree that the average PT should be most concerned with EBP, but administrators (Licensed PT'S), owners, retirees, need to focus more on the legislative, RFP, et al situations affecting our profession.
But my question is, how many staff PTs are really concerning themselves with RFP, negotiating insurance contracts, and MCR reimbursement?
Not many unless they are being groomed for an admin position, is my guess. If they are interested, APTA gives them very quick and easy access to their local Congressmen. More importantly, APTA also gives access to Cochrane.
Is it truly that PT's are focussing too much time on other issues or that they're not focussing on any issues? With all the resources out there, doesn't it come down to the old proverb: "you can lead a horse to water, but you can't make him drink"?

[Selena Horner]

Sean, if the majority of physical therapists are not association members, how aware are those therapists of any issue? If a therapist isn't an association member, then probably the biggest influence as to how that therapist practices is administration within the organization employed and the mentorship of other therapists within that same organization. So, technically, has the horse been led to the water?

The cycle of the budget needing revenue and providing a service to gain revenue in a fee for service reimbursement system with no reward for efficiency or effectiveness with a behavioral focus on productivity which only monitors the average units billed/hour realistically doesn't open the doors to motivate anyone to practice with evidence. Instead, it creates an environment where aides are sometimes utilized to capture units and double booking occurs to ensure that the productivity requirements are met.

To practice with evidence requires a different business scheme.... monitoring outcomes (visits, level of function AND treatments), a rewarding tier for therapists for visits, function or both, an excellent marketing plan that maintains a continual flow of customers because the turn around time may go from 6 weeks down to 3-4 weeks, which means a greater population of people would need to be treated annually to reach the same profit level, maybe. It actually could be MORE profitable to practice EBM... evals have a higher monetary return so for example, if a therapist generally evaluates 100 patients per year, but IF efficiency and effectiveness improved, one might be able to evaluate 250 patients/year. If the majority of the passive, low paying, least effective treatments were eliminated, one is left with higher paying, more effective treatments for generating revenue.

It would be interesting to know if most therapists are internally motivated or externally motivated. The majority of management/monitoring systems definitely do not lead a physical therapist to think EBM and most management systems don't even provide feedback to physical therapists about their individual performance except at the level of their productivity. I'd assume that a combination of a change in the business model, a different focus in measuring performance and a reward for desirable behaviors would be the ticket in increasing EBM.

[John Ware]

Sean,
PT's don't focus on these legislative issues because they don't trust the political nonsense that is inextricably tied to it. Many just tune it out.

I've had my ear to the legislative ground for most of my more than 12 years of practice. I see very little progress on the legislative front despite the extraordinary efforts of many individual PTs and the APTA. Look at the ridiculous Medicare cap issue that has been playing out for at least as long as I have been practicing. Every year, I get that doomsday email from APTA that the sky is going to fall if we don't contact our congressmen to get the cap repealed. It reminds me of the movie "Groundhog Day," except in this endless loop, nothing ever changes.

I think you have it backwards. You say that other professions are trying to legislate us out of existence, so we need to keep up the battle in the courts and legislatures to support what we do. I, on the other hand, think we need to focus on getting our patients better in the most cost-effective way, and thus PROVE our value in the health care system.

I base my comments on the larger picture that shows our current health care system in a severe financial crisis, and figures showing Medicare going bankrupt in the next 10-15 years. The lack of results-based treatments throughout our health care system is running it into the ground. There is a profound lack of excellence for treating common medical conditions, not the least of which is LBP.

PTs are at a critical juncture where there is strong evidence mounting supporting our interventions, but many if not most are unaware of it. Even a majority of OCS's use US to "promote soft tissue healing"!

If we spend more of our time and efforts promulgating the benefits of implementing EBP and results-based interventions among our colleagues, then the value of PT will be evident, and then professional stature will rise accordingly.
John