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Check Out the Upcoming EIM Courses!!!

Check out upcoming Evidence in Motion courses currently open for registration! Learn more about MyEIM and our new Articulate course format!

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***Indicates course open for internal registration only. Contact facility POC listed on website.

Evidence-based Examination and Selected Interventions for Patients with Lumbopelvic Spine and Hip Disorders

Nov 3-4, 2007***
Hawthorne, NY (USA)

Nov 17-18, 2007***
Greenville, SC (USA)

Jan 26, 2008***
St. Louis Park, MN (USA)

Mar 29-30, 2008
Portland, OR (USA)

April 5-6, 2007
New Braunfels, TX (USA)

Evidence-based Examination and Selected Interventions for Patients with Cervical Spine Disorders

Oct 27-28, 2007***
Evansville, IN (USA)

Nov 3-4, 2007***
San Luis Obispo, CA (USA)

Nov 17-18, 2007
Fairfield, CT (USA)

Jan 12-13, 2008***
New Milford, NJ (USA)

May 31-Jun 1, 2008
New Braunfels, TX (USA)

Evidence-based Examination and Selected Interventions for Patients with Upper Extremity Disorders

Oct 26-27, 2007***
Ft. Lauderdale, FL (USA)

July 26-27, 2008
New Braunfels, TX (USA)

October 4-5, 2008***
Green Bay, WI (USA)

Evidence-based Examination and Selected Interventions for Patients with Lower Extremity Disorders

Nov 10-11, 2007
New York, NY (USA)

Feb 2-3, 2008
New Braunfels, TX (USA)

We encourage early registration to insure a seat. Extensive hands-on lab sessions are included.  Visit us on the web at www.evidenceinmotion.com to get more details, learn about other 2007 course dates and locations. Register online today!

Feel free to email us at courses@evidenceinmotion.com if you have any questions or need additional information. Consider passing this post on as an email to your colleagues who might benefit from this information. Hope to see you at an Evidence in Motion course in 2007! We sincerely thank you for joining with us to translate evidence into practice.

The Evidence in Motion Team

Spine Surgery: Unethical Behavior at its Best

One of the more frightening journeys one can take through cyberspace involves researching surgery of the lumbar spine.  It's one of those instances where the internet becomes an agent of clarification and the results are always quite disturbing.  This is not news to readers of this blog.  Both in our daily clinical practice and through prior postings here, we are frequently reminded of the pending disaster that is spinal surgery.  In my own mind with respect to spinal surgery, an ounce of prevention is worth about 735,000 metric tons of spinal surgery revision hardware!

September and October 2007, have been full of news in which spinal surgery ethics...or lack thereof, has gotten some pretty good play.  Let's us start with a visit to Consumer Reports, which lists (again) spinal surgery in its series on medical ripoffs. 

Next, we can go to the New York Times as it investigates the nature of payments made by the enormous medical device manufacturer, Medtronic, to surgeons.  How does $400,000 for 8 days of work sound? 

Do you want to read Sen Grassley's letter to Medtronic (pdf)?  It's pretty good and included such demands as:

3. Please provide the Committee with a list of all payments or other transfers of
value made to the following individuals: Lawrence G. Lenke, Jeffrey C. Wang,
Behrooz A. Akbarnia, Thomas A. Zdeblick, Rick Delamarter, David Polly, Kevin
Foley, Kenneth J. Burkus, Regis Haid, Rick Sasso, K. Daniel Riew, Steven
Garfin, Choll W. Kim, Scott Boden and Stephen Papdopoulos. For each payment
or transfer, please include the date, amount, and reason for the payment or
transfer. This request covers the period of January 2000 to the present.

Astute readers may note that the name, Dave Polly, comes in question in both the NYT and Sen Grassley's letter.  It may be interesting to also include that Dave Polly, an ex-Army orthopod, famously considered himself the "Michael Jordan of Spine Surgery."  I wonder if that was spoken in the third person.

Better yet, make a visit to the news page at the Association for Ethics in Spine Surgery.  It is comprehensive and enlightening.  Why you're at it, consider joining the group in support of its mission.  Membership includes simply agreeing to stand against unethical surgery.  No brainer!

I often write about areas where I feel therapists have an opportunity to promote their services and expand our profession.  This situation certainly fits that description, but it is far more than a marketing opportunity.  It is our duty, as practitioners who have the ability to prevent chronicity of spinal pain in a tremendously cost-effective manner, to educate consumers, the regulatory bodies, the press, and others about this travesty in health care.  It is our obligation.

Side Story:  Just last week a good friend had her gall bladder removed after being diagnosed with gall stones.  When her symptoms did not change, the surgeon informed her that no stones were found and the pathology report was normal for her now absent organ.  Turns out, the diagnosis, and surgery, proceeded on the word of the ultrasound tech, who assured the surgeon that she was looking at gall stones during a phone call immediately following the exam.  No radiologist was consulted, no image was ever viewed by the surgeon.  My friend's organ cannot be returned, however, her bill did arrive on time.  Unethical surgery is a real problem.  It exists.  We need to stop it!

ERIC

Drop Outs and Co-pays

One of the many “push backs” I get from PT’s, is the effect of higher co-pays that patients have encountered in physical therapy visits which result in less visits.  Many therapists have stated that this has had a significant impact on their practice.  I am sure that their analysis is correct but does the drop out (less visits) have an impact on outcome?

Before I attempt to go there, let me first state emphatically that I believe co-pays are a barometer of your practice.  If patients don’t see the value that they are obtaining from their PT experience, they are certainly much more likely not to come back.  A physical therapy referral is unfortunately an ambiguous one.  Patient’s know what to expect when they get a referral for an X-ray, lab, or pharmacy.  Research reveals that they are not quite sure what to expect when they get a PT “script”.  Not long ago, I even had a patient that went to a pharmacy with one of these scripts (the patient thankfully wasn’t given a generic!).  It’s our job to not only shape the expectation for the patient but also to demonstrate the value they are receiving from their encounter with us. If we achieve both of these, despite higher co-pays, they will return certainly for enough visits to achieve a solid outcome.  Yes, there are on occaission the patient that has to choose “milk” or “drugs” versus PT but this is more the exception than the rule.

For a historical perspective on this whole “co-pay” notion, one has to appreciate the significance of the RAND Health Insurance Experiment (HIE).  In the 70’s, RAND randomly assigned thousands of patients with varying degrees of health insurance co-pays and followed them for five years to try and determine their medical utilization health.  The lessons, essentially now the gold standard in private insurance, demonstrate that utilization is altered by degree of co-pay (inversely) but that health outcome was not adversely effected by higher co-pay for the average person (differential effects exist for the sick and poor).

Recently, the HIE has come under some very interesting criticism from John Nyman from the University of Minnesota, that appeared in the Oct 2007 issue of the Journal of Health Politics which outlines some sharp criticism of the HIE and the fact that there were so many volunteer drop outs over the 5 year period (LBP surgery research-are you listening?).

So, back to the question: are higher co-pays impacting your practice?  If so, are the drop outs voluntarily based on their amount of co-pay or the value they are getting out of their visit?  Are the shorter visits per patient having an impact on the patient outcome?  Thats a question that only you and your clinic can accurately answer as great variability exists across the country in amount of co-pays.  Lastly, I believe that the unintended consequences of higher co-pays has further propelled one of the biggest misperceptions in our profession-that the role of outpatient PT is to provide a Home Exercise Program.  A misperception that we have in fact fueled to a certain extent.

Thoughts and your experiences on any of this is helpful.

Larry@physicaltherapist.com

AAOMPT 2007 in St. Louis a HUGE success

It was obvious from the first moment of the opening reception that this year's annual conference was going to be fantastic.  Although I didn't get to take advantage of the pre-conference courses I was quite impressed with their content and made a mental note to reexamine my schedule for next years travel plans to Seattle Oct. 29 - Nov. 2, 2008.

This year's conference was full of connecting with other members, fellows, and a rapidly growing number of students.  Opportunities to hear first hand some of the latest research, a jammed packed evening of posters with good wine and cheese, time to learn a few new manual therapy techniques, collaborate with other manual therapy educators, and even had a few celebrity sightings.

I even heard rumor that the AAOMPT president showed executive posture in handling all his motions from an instrumental vantage point...in and OUTside the buisness meeting.

Special thanks and recognition needs to be made for Lisa and Eric Furto for the
tremendous effort and time they put into making this without a doubt the best conference I have personally attended to date. Thanks to you both...and I look forward to Seattle!

ab

Managed Care vs. Care Management

I remember once reading an article several years ago in which  brilliant author Dave Berry dissected 2 different Presidential primary candidates’ stump speeches.  The point of his article was to show you that a good political speech can have have all of the words of its sentences scrambled and paragraphs interchanged and the message of the speech will not change at all.

Borrowing this same technique, health insurers are now recasting managed care as care management.  I ran across this and other tidbits while reading the very respected Center of Studying Health System Change (HSC) most recent report.  HSC is typically very insightful and uses detailed surveys of the metropolitan health care markets to describe trends in health care.  It’s an easy report to read but if you don’t want to waist your time-not much has changed recently and although some aspects of consumerism are occurring, the bottom line is that little really has changed since 2005.

Care Management trends are showing that pre-authorization is coming back-albeit a little more sophisticated in terms of the use of IT and “real time” data analysis.  This can be both concerning to PT as we long remember managed care’s (as it was known then) tendency to make us go thru the “hoops and ladders” of visit authorization, approved codes, and artificial limitations in coverage and intervention.  All of this was purported to be going away due to provider backlash.  Under Care Management (as it is known now) it is on the rise.

In fact, providers are buying UM vendors and incorporating them directly into their processes-particular for imaging where some select providers are given a “free pass” based on data while others have to go thru the pre-auth process.  Apparently, the “free pass” is based on utilization data and history of those providers.  Specialty pharmaceuticals and bariatric surgical providers are also on the radar screen of these processes as well. 

Don’t be too surprised when (not if) this hits the physical therapy industry.  It will be in Yogi’s words “Deja Vu all over again” but we will feel better because it is now called care management.

Thoughts?

Larry@physicaltherapist.com

 

This story isn't so hip!

Some days it seems I need to search high and low for good blog fodder.  On other days, the story seems to write itself.

Yesterday became one of those days when I clicked on the NEJM RSS feed in my reader.  An article about the care and treatment of hip OA by Dr. Nancy Lane, was one of the new articles in this month's issue of the New England Journal of Medicine.  The editors obviously thought highly of the piece, because they attached continuing education credits for reading it if you were to take the following quiz.  I was excited to see the medical community take a step toward reconciling their lack of musculoskeletal competence, however small, with this article. 

The piece started off normally, with examination and interpretation of findings, but as the article progressed to treatment I found something sorely lacking. The physician writing the piece skipped right over any details about a physical therapy intervention for this patient.  Recommended were meds, an education program, and an aquatic exercise program.  It wasn't until the final conclusions that the term "physical therapy" actually makes an appearance and the term "joint mobilizations" was absent altogether.  Dr. Lane did include acupuncture and "periodic telephone-support interventions by lay personnel" as treatments with supportive evidence, however.

A recent editorial in JOSPT (Journal of Orthopaedic and Sports Physical Therapy) thinks quite differently about how to treat an arthritic hip.  In "First-Line Interventions for Hip Pain: Is It Surgery, Drugs, or Us?" Wainner and Whitman discuss exactly the patient population which the NEJM article presents.  Their editorial outlines a variety of compelling evidence about the under-utilized, yet effective role physical therapists play with this patient population.

I'm not surprised that the Dr. Lane presumably had not read their editorial.  After all, what motivation does a physician have to keep up with PT literature?  Especially when they are so busy working as a consultant:

"Dr. Lane reports receiving consulting and lecture fees from Eli Lilly, Merck, Procter & Gamble, Wyeth, and Roche and grant support from Procter & Gamble, Amgen, and Rinat Neuroscience."

Which is another story in itself!

Hey, everyone's got to make a living right?  Regardless of who pays who and for what, the bottom line is that there is a standing lack of respect for Physical Therapy literature.  Perhaps we speak "gibberish" to the docs, perhaps they don't have the construct to understand manual therapy interventions, perhaps it is more of an institutionalized opinion among physicians that contributes to this oversight.  Whatever the cause, I can only presume that more good evidence, from our group to theirs, can only help our cause. 

Until then, I'm thinking of sending Dr. Lane an e-mail to let her know about how effective physical therapists can be with this patient population. 

ERIC

PT Practices have to stop behaving like chimpanzees

There is an economic principle exemplified in a model called “the ultimatum game”.  Under its scenario, one person (the proposer) is given money by an experimenter.  The proposer can then divide the money with a second person (the responder).  The responder has quite the power.  If he accepts any offer, he gets to keep what he accepts. On the other hand, if he rejects any offer, neither the responder or the proposer get anything.  Typically, the proposer offer something in the range of 50% because anything less is more often than not rejected.

A recent study done on chimpanzees, showed that unlike humans, they will often settle for taking any non zero offer (e.g. way less than 50%) and this supports the theory of “selfish-economists” which has not been shown in humans.

After reading about this study in Science Daily , it occurred to me that PT practices need to act more like social reciprocators rather than like chimpanzees.  Why do we accept contracts way below our cost?  Why do we believe that “any” reimbursement is better than none?  Why do we let the insurance “proposers” get the most when we hold significant power as responders?

Thoughts?

Larry@physicaltherapist.com

Does A lot of Information Result in Better Choices?

On Friday, Bill Gates had an op-ed piece in WSJ (available for non-subscribers for 7 days).  He correctly points out delivery of health care is in a crises (the system itself is the 5^th leading cause of death in US).  Despite the volumes of money spent in the system, it is fragmented greatly with respect to collection of information, redundancy in tests, and the ability to aggregate information from disparate sources.  Bill even correctly  refers to the 2001 Institute of Medicine report adopting information technology and use of EBP in his position that part of the answer is an internet-based health care network. 

The health care industry can only benefit when brilliant thinkers like Bill Gates make it a mission to intervene.  I am quite sure these efforts will result in some needed improvement.

My criticism is in the assumptions that many make when it comes to consumer information and that somehow more information and options leads to better decisions.  There is no question that when a physician is able to access a myriad of test results coming from different sources that somehow make it way to one patient health record that this can only lead to better diagnostic decision making.  But the consumer?

One need to only look at the options that a consumer has for LBP.  Information and treatment options are rampant in every community and a simple search on the internet will lead to over 23 Million links, images, and options.  Has this much information lead to better treatment?  Data would clearly indicate otherwise.

The fact of the matter is that patients trust their medical providers to give them the best options.  The best options seem to be the one’s without too much choice or options.  In fact, according to social scientist Barry Schwartz and his book the Paradox of Choice:Why More is Less, too much choice can cause “genuine suffering”.  Perhaps the ridiculous number of options in the treatment of LBP in fact contributes to more of the problem!

There have been a plethora of research studies (with a lot of replication) that show for example shoppers that were offered free samples of 6 different types of jams were more likely to buy than shoppers who were offered 24 different types.  Students offered extra credit for writing a paper with 6 different options were more likely to do it versus students who were offered 30 different options.  Different contexts of these studies have always produced the same results.

One of the advantages of using clinical prediction rules and categorization in general for many different treatment diagnoses is the fact that it produces a limited number of options which results in better care and better satisfaction than the unlimited variation and randomness that occurs throughout consumer choices for care of a multitude of problems.

Integrating “limited options” in your clinical care utilizing EBP and a digital internet health care revolution may just be Bill’s secret sauce for making an impact in the industry.

Thoughts?

Larry@physicaltherapist.com

WalMart Effect - Any similarities?

I have wondered lately if we are not in a similar position as the local 5&10 stores or Local Hardware stores of the 1970/80's.  As their businesses became more of a commodity the Wal Marts and HomeDepots began to take over - living off higher volume and lower margins making it difficult for the little guy to compete.   As we become more of a commodity, insurers are trying to force the PT practice into the higher volume and lower margin model.  This would seem to mean that the PT version of Walmart and Home Depot may be looming on the horizon.  To have a margin (remember "no margin, no mission") this model would be one option.

The question is could the mom and pop stores have changed their strategy to have survived or was it inevitable?  What alternative model can we adopt to prevent this from happening? 

If you look at the article in today's WSJ - "Wal-Mart Era Wanes Amid Big Shifts in Retail", things can swing (http://online.wsj.com/article/SB119135657404946747.html?mod=djemITP)  Walmart is apprently losing some of its control on the marketplace - in fact the article says:

"For the first time in a long time, quality has a chance to gain on price," says Lee Peterson, a vice president at Dublin, Ohio-based brand consulting firm WD Partners Inc.

Can we create the market forces that produce this swing in our profession?  Can we be creative enough to not be "Wal Marted" any further?  I beleive we can if we get enough of the right people on the same side of the problem and use that synergy to create solutions that we can't see from where we are currently sitting. - Jeff

A new definition for "group" Therapy

Old topic making new inroads-even the Army is getting into the act.  I guess we should be grateful to see PT’s on Engadget one way or another.   Don’t they say that any PR is better than none?

Larry