File this post under “why there is a blog focused on evidence based practice in physical therapy”.
One of my favorite healthcare bloggers is Joe Paduda and his Managed Care Matters. I find many of his worker’s comp particular posts informative. A few weeks ago, in response to the NY Times Gina Kolata article, Joe responded with a “How many dollars are wasted on physical therapy?” post.
In subsequent comments and updates (particularly in response to a very detailed comment on his blog), Joe provided further clarity and data to his post (at bottom of page). It would be very hard to disagree with some of his more significant points-PT is in fact a “black whole” in worker’s comp and there are far too many providers that take advantage of worker’s comp first dollar coverage and see patients for hundreds of visits.
My advice Joe would be to dig deeper into the data and marketplace and you will find some interesting things including:
Over-utilization:
We agree that physical therapy is often over-utilized. Which is really quite amazing when you consider that NO physical therapy is rendered in workers’ compensation without a physician referral and authorization by the payer. So how is it possible that PT would be so abused?
Answer: PT has become a “money machine” for the very physicians who are supposed to be the system “gate keepers”.
As “gatekeepers” physicians enjoy unfettered control of the physical therapy market, having the exclusive authority to prescribe the service while at the same time owning the clinics to which they refer.
By design this conflict of interest is rampant in comp and growing exponentially.
And what’s so puzzling is that in spite of the evidence that this conflict of interest results in lower quality of care and is a major cost driver, neither the regulators nor payers have shown any initiative in dealing with it.
-Practice Guidelines:
You are right about the scarcity of published guidelines for PT - what to do and for how many visits. However, there are currently significant efforts underway to establish PT practice guidelines for the most common conditions encountered by physical therapists. Although these guidelines are not specific to work comp, the recommendations certainly apply to the large majority of work comp cases and will help inform best practice for both work comp cases as well as the care of patients from other payer sources. Bear in mind that although practice guidelines are certainly a start, they certainly no panacea for the problems in work comp given their inability to effect behavioral changes consistent with guideline recommendations unless other reforms are brought to bear (i.e. payment incentives to simply do more procedures rather than generate an optimal outcome). Also, before we get too critical on the lack of guidelines for PT, where are the guidelines for orthopedic surgeons and pain docs?
One area where we have quite adequate guidelines to inform optimal PT management is low back pain, which as we know is one of the highest cost drivers in the entire health care universe. The recent ACP-APS guidelines on the non-surgical management of low back pain is a very good example of this. Again, the problem is not so much the lack of guidelines as it is the abundance of perverse payment incentives and conflicts of interest (ie, physician ownership of PT) that encourage everything but adherence to best practice according to practice guidelines. There are in fact providers following the best EBP guidelines and producing extraordinary outcomes but due to self-referral patterns and the fragmented work comp system, they are often times simply cut out of the system. Or, to make matters even more egregious, these same independent, outcome-driven providers are actually “punished” by a system that rewards doing more procedures rather than rendering good care.
-While you acknowledge the potential conflict of interest by citing Medrisk’s “most thorough published” (an arguable point by the way and one in which I think you are misguided) Expert Clinical Benchmarks, I would argue that they (Medrisk) contribute to the problem. Take a straw vote and you will find that their adversarial “just say no” relationship with providers has caused a significant number of the top quality providers to opt out of plans in which Medrisk is involved.
“Managing” care by simply denying it may be good for MedRisk’s bottom line but is simply a capricious exercise in rationing care, which survives only because there are no clinical outcome performance metrics monitoring the consequences.
Too little care is probably more problematic than too much due to the significant downstream costs of imaging, drugs, and surgery-particularly in LBP.
Joe, you’ve posted before on the topic of how these PPOs and TPAs have turned the process into a profit center. At the same time they pay providers below their costs, often time 50% below Medicare rates.
We believe the system has been bastardized to the extent that costs are needlessly out of control while injured workers are being shortchanged and denied access to the very care they need for early return to work.
If professional football players were covered under workers’ compensation rules the NFL wouldn’t be able to field a single team.
Joe, how about a post in Managed Care Matters about the potential of significant savings of work comp dollars by disallowing conflict of interest referral for profit situations, contracting only with independent PT providers who “show your their guidelines, how they comply with them, and their 3rd party produced outcomes”.
Thoughts?
larry@physicaltherapist.com, john@texpts.com, rick@physicaltherapist.com
