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The Rise of "Integrative Medicine"

Many of us in the world of scientific medicine (which naturally includes the readers of EIM!) have been alarmed at the steady rise in popularity of the so-called "Integrative Medicine" movement. The following consists of my personal opinion and commentary on this topic.
For those unfamiliar with the term "Integrative Medicine", here's the WebMD entry: IM

The Wikipedia entry is a little more telling: Integrative Medicine. As of this writing, it redirects you to the "Alternative Medicine" entry. Interesting.

So what gives? I think IM is theoretically an attempt to combine some popular alternative methods into standard science/evidence-based care. This might be due to the desire of the patient to have some of these therapies, or a desire of the practitioner to be seen as "open-minded". In practice however, I think IM is the combination of dubious (and often ridiculous) treatments with standard medical care. Therefore I think it typically results in the addition of nothing significant at the risk of conveying some dangerous ideas regarding the nature of medicine and the role of the practitioner in healthcare. For example, the responsibility of the practitioner to be an "honest broker" about the patient's healthcare options and the science and evidence underpinning those options.

There have recently been some articles in the mainstream media about the IM movement, both on MSNBC and on Fox News.

As usual, both Quackwatch and the Science-Based Medicine blog are excellent resources on this topic.
Quackwatch on IM
SBM on IM

I think we've all seen some examples of integrative medicine in physical therapy clinics. Perhaps you've seen a colleague provide a treatment of questionable value in addition to treatments you thought made sense. I know I have.
I don't think much of IM myself, and I make sure I have a good answer when patients ask me why I'm not using this or that alternative method. I feel that's an important part of my responsibility as a healthcare practitioner.

I close with a quote from Dr John Farley PhD, found at the Quackwatch link. I think it encapsulates the issue perfectly.

"Integrative" medicine is purportedly combining alternative and mainstream approaches to medicine. The claim is that integrative medicine provides the best of both approaches. This may sound reasonable, but actually it is not. Suppose that the "integrative" approach were to spread beyond medicine, and were to be more broadly adopted by other disciplines in the sciences. The biologists would "integrate" creationism with Darwinian evolution, while the chemists would integrate alchemy into modern scientific chemistry. The geologists would integrate the belief that the world is only 6000 years old (and flat) with modern dating of rocks. Physicists would integrate perpetual motion machines with the conservation of energy and the laws of thermodynamics. And the astronomers would integrate astrology and astronomy. Of course, this is ridiculous. It's not a good idea to integrate nonsense with valid scientic knowledge."

What is the proper role of IM in physical therapy, and what are its boundaries? What do you think?

-Jason Silvernail DPT

Ingenix and their phony database

Kudos to Andrew Cuomo for finally busting Ingenix and their “usual and customary” database.  Ingenix is part of our good friends UnitedHealth Group-easily the most detested payor in the PT world.

The problem is that Ingenix is also hired by most states to help set their work comp rates.  They “sell” their independence from UnitedHealth Group in setting these rates but who cares-we now know their database integrity is to say the least lacking.

By way of background, the case started in 2006 when a patient was left with huge bills for ovarian cancer despite supposedly having full insurance.  Apparently, in the Ingenix routinely publishes phony numbers that look like they will reimburse X when the reality is that it is reimbursed Y.

For example, let’s say an out of network patient comes in for a PT eval.  Their database might say that “usual and customary” is reimbursed $100 for PT eval (ok, bad example but you get the point).  However, the payor reimburses $70 and leaves the patient with a $30 bill.  You can imagine the frustration a consumer has when they assume that it is being reimbursed at one rate and it ends up quite another. In the case of something like cancer, it can be huge dollar differences.

The settlement of $50 million isn’t much for a company who gave their CEO more than 10x that in options, however, the other part of the settlement is for an independent non-profit to develop and manage a real database. Real transparency might be around the corner-not sure if this will bode well for practitioners or not but at least patients will have a better clue as to what they are paying.

 

larry@physicaltherapist.com

PT Twitter Just a typical day in Tweetdom

 

	smartsuggest : California: American Physical Therapy Association (1921- ) - ... http://tinyurl.com/6ldop2 Reply
	miseasons : Physical therapy assistant degree program announced: North Central Michigan College, Alpena Community C.. http://tinyurl.com/6pja7o Reply
	organidog : Day One of physical therapy... not too shabby, still a bit sore. Reply
	pattiiii : After a strenuous physical therapy, mood swings up the ass, and a loud family, i think i deserve this much needed sleep Reply
	mansibhatia : Mansi is off to physical therapy. http://ff.im/-6qzo Reply
	smartsuggest : California: American Physical Therapy Association (1921- ) - ... http://tinyurl.com/683gxq Reply
	mdfsmash : Mostly good news on my knee - need orthotics for my shoes, going on short course of anti-inflamatory meds, and 4-6 wks of physical therapy. Reply
	DevHawk : taking an extended lunch with the kids while jules is watching Mom-in law's physical therapy Reply
	Marcstar : Ooh rah! Kicked some ass in physical therapy! Reply
	SueLang : Back from 1st physical therapy session for knee. Will take some work to regain range of motion. Reply
	CoreyTuttle : Nothing like a warm cup of physical therapy in the morning... Reply
	smartsuggest : California: American Physical Therapy Association (1921- ) - ... http://tinyurl.com/5obccr Reply
	saturnswirls : just got home from physical therapy. Reply
	wmrandth : Proctoring final Physical Therapy student exam for the year ... told them they could feed the fish in aquarium if they were good... Reply
	digitalmayhem : Awake -- need to go to physical therapy (thank goodness there is only 1 more week, i'm so sick of going there!) Reply
	GetPTAJobs : Licensed Physical Therapy Assistant - Asheville, NC http://tinyurl.com/5lqu72 Reply
	LJWolfsohn : Getting ready to go to physical therapy and then off to clients....long day ahead Reply
	Minako06 : Why did I schedule my physical therapy for so early? Why? I hate mornings, especially cold, winter-y ones. Reply
	OnYourWeb_net : http://OnYourWeb.net Back Pain Solution Guide By Doctor Of Physical Therapy, He.. http://bit.ly/VQaV Reply

 

Not sure how many readers of this blog are on twitter, but the above results represent a typical day’s reference of physical therapy tweets!

PhysicalTherapy on Twitter.

 

larry@physicaltherapist.com

Stop the Merry Go Round- Direct Access Please!

The Problem: Timely access and provider choice for patients in the UK who need care for musculoskeletal complaints but have to wait months to get an appointment with a General Practitioner (so they can then be referred to a Physio). 

The Solution: Direct access to services provided by a physical therapist 

The Result: Swift, effective care for people of all socioeconomic classes with musculoskeletal disorders leading to reduced work absenteeism, reduced direct costs, and increased patient satisfaction (per the published govt. report commented on in this article). Oh yea, also employment for the 1,800 physiotherapists who have graduate since 2005 and want to treat patients but who cannot find work. 

One quarter of all consults from General Practitioners in the UK are for patients with neck and back pain complaints alone. What are they able to offer these patients?   Hmmm, it appears the “You have Drugs, Surgery, or Us” option applies internationally…it certainly does in this case. 

The Department of Health is calling on the leaders of the NHS to allow direct access. The APTA and its membership has been doing the same for some time now. Excuse me legislators and key health care decision makers: This is not rocket science- what’s not to get? 

Round and round and round we go, when will this madness (Medical visit ------ Consult ----------PT) stop nobody knows. However, one thing we do know, and that is that it won’t stop until our patients have the option and ensuing benefits of real (ie. unfettered and reimbursed) Direct Access.

 

Rob

Blue Cross of Minnesota will no longer pay for Manual Therapy

Over the past week, private practice PT owners have been receiving this provider bulletin (P22-08) Download post71a_125818.pdf in their mailboxes. Briefly it states:

Massage and manual therapy exclusion
Effective January 1, 2009, Blue Cross and Blue Shield of Minnesota and Blue Plus will no longer reimburse providers for massage or manual therapy services. Massage or manual therapy will deny either as incidental (provider liability) or subscriber liability.

Massages that are provided as preparation for a chiropractic manipulation or other physical medicine therapies, are considered an integral part of the chiropractic manipulation or other therapy. As such, we will deny it as provider liability. If a massage is billed alone, then it will be denied as a subscriber contract exclusion.

Codes
97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97140 Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

Liability
Provider liable:
Massage and manual therapy (97124 and 97140) will be denied incidental (provider liable) to chiropractic manipulations or other physical medicine procedures billed on the same date of service. The denial will be upheld regardless of submission of the -59 modifier. Additionally, submission of the -GA modifier will not affect or change the denial.

I found out about this Monday night and quite honestly said, What the Hey!! and immediately fired off emails to MN APTA, APTA, EIM team, friends, co-workers, etc.  Others have done so as well.

As of this morning, a  unified effort is taking place.   The MN chapter of the APTA is trying to get some answers from BC of MN and determine when and with whom we can meet to discuss. At present, Blue Cross of MN is not being very helpful.  Nationally, the APTA is aware of the issue and waiting to help if the matter can't be resolved by the MN Chapter and PT providers in a timely manner. 

In Minnesota, lots of theories are circulating as to exactly why and what Blue Cross was trying to do here.  From a research perspective, the recent September JOSPT Neck Guidelines and articles like the one by Walker et al. that came out in Spine today make supporting the efficacy of manual therapy and it's use with exercise a slam dunk. 

Hopefully we will have some answers soon.  I will keep you posted.  Could your state be next?

JW Matheson DPT

Image taken from here - see free use policy

Yes Virginia, Even You Can Have Your Own Personal Ultrasound Unit

I am known for my horrible taste in Holiday gifts.  I would much rather fly the whole family to Montana for a week of skiing than exchange gifts under the tree. Also, I like gift cards and I give gift cards. Perhaps it was the "Chia Pet" and "The Clapper" I got some family members on that Christmas a decade or more ago that sealed the acceptance of the token gift card. 

This past week when a patient brought an ad for a home ultrasound device into the office, I began to rethink the gift card thing.  Why don't I just get everyone their own home ultrasound device for the Holidays.  According to the information on www.ultrasoundcure.com their portable ultrasound units are:

"radically changing lives and the professional therapeutic community. A low cost, safe, easy to use unit allows professionals to provide their patients with units to take home and use for the duration of the healing process. This means you can get your treatments 3 times per day, every day, instead of just a couple times per week. That's 10 times as often - 10 times the benefit - meaning a much less painful and more speedy recovery"

Sounds (that's a pun) like a nice gift for the loved one - doesn't it?  Just wait, if you order now you get more because:

"The units come with our naturally medicated ultrasound gel that, through the process of phonophoresis, delivers anti-inflammatory and pain relieving ingredients deep into the body. Together, the combination of phonophoretically delivered medications and regular ultrasound therapy provide incredible pain relief and speed the healing process."

Please check out the links above.  The website is full of a lot of additional information about how ultrasound and its healing properties can help athletes and those experiencing chronic pain. The units are priced at $99. This price is only guarenteed for the next week.  But wait, like the above quoted statements, the website also claims that:

"If you don't have your own Portable Ultrasound Machine, don't worry. All on its own, MendMeShop Gel is an effective therapeutic product when massaged directly into the skin. If you're curious about the difference between applications with and without ultrasound you can always visit your local physical therapist or chiropractor with your own bottle of gel. They should be familiar with our product and its application."

So help me out, I really wanted to get Larry, John, and Rob at EIM something for the upcoming Festivus season.  Should I go with the home unit and Bulgarian lavender infusion gel - or perhaps stick to the basic Starbuck's gift cards?  As always, I look forward to your comments. 

Good For Physical Therapy?

A frequent topic on this blog is physical therapy marketing and PR.  I thought that a recurring discussion regarding this topic would be appropriate.

One of my favorite magazines is Fast Company.  They always seem to be on the cutting edge of technology and present a full ranges of stories that you just don’t get from traditional media sources.

This month there is a feature article entitled:  The Most Valuable Player in Sports Medicine: James Andrews by Chuck Salter.  The article details the significant expertise, acumen, and history of Dr. James Andrews who is unquestionable this country’s pre-eminent sports medicine physician.   He is not only a skilled craftsman but obviously a great marketer and business generator for all aspects of this part of the health care chain.  It also details the problems Dr. Andrews got into with Healthsouth and the $450,000 civil settlement that he paid regarding potential self-referral laws.

The article also points out that two thirds of the patients that are seen at his clinic and in particular the PT clinic are not sports figures but everyday Joe Lunchpales.   Dr. Kevin Wilk, who has worked for/with Dr. Andrews for 19 years is somewhat featured (well, at least his picture is in the article and he is mentioned).  Without question, Kevin is a noted authority in sports medicine, well published, extremely engaged within our professional association, and lectures internationally.  (side note: the online article due to typesetting is portrayed differently than the print copy which shows the athletes that Dr. Andrews has consulted or operated as the front page of the article).

Fast Company is read by thousands of influencers in the U.S. and this is a particularly significant marketing for Andrews and his clinics in Alabama and Florida.  You could not buy a better medium to have an article about you or your service.

However, I was particularly disappointed by the lack of emphasis on the rehab component of sports medicine in the article.  In my opinion, it is treated sort of like an old school “after care” type of program and approach with the surgeon of course getting the top billing.  Perhaps I am being just a little sensitive and defensive of our profession and the fact that many surgeries’ outcomes are driven by the rehab component than the surgery itself.  I also realize that the gist of the article was deliberately about the surgeon! 

For discussion, I would like to hear the thoughts and opinions of the EIM readership. 

Is this article good or helpful for our PT profession?  Does it portray PT accurately?  Does it put PT as subordinate to physicians?  Should we promote this kind of article to the mainstream through press releases and highlights? 

larry@physicaltherapist.com

Marketing with Legs

The New Jersey Society of Independent Physical Therapists (NJSIPT) exists to support physical therapists in independent practice.  You've got to love their website, which includes a rationale for their existence:

Presently, the NJSIPT has identified several areas of concern that directly impacts the Practice of Independent Physical Therapists.

· The continued decline in and inadequacy of third party coverage for Physical Therapy benefits

· The cumbersome authorization process required of practitioners to provide care for patients

· The infringement of Non-Physical Therapist Owned facilities and providers on the practice of Physical Therapy has continued unchecked

It has become evident that there is a need for an Organization whose sole Mission is to serve the needs of Physical Therapists in Independent Practice.

As part of a state-wide marketing campaign in support of independent PT practice and pending legislation, Vice President, David Bertone, and Executive Director, Ken Mailly sat down and created a 30 minute video presentation targeted to consumers.  The format is a news talk show, and is part of a regular series that Bertone produces, which is targetted towards residents of Old Bridge, NJ.

I have to say, I love marketing efforts like this.  The act of getting out into the media may seem intimidating, but is highly necessary.  This video gets into some pretty intensive PT industry problems (Direct Access and Reimbursement), after first sarting out with basic physical therapy information.  I'm not sure that I would stick through it if I was a consumer without a particular interest, but this is solid work and can serve as a model for everyone out there to create fresh ideas for marketing. 

The internet makes media production like this very powerful.  As I post this, the video grows legs larger than the 30,000 residents of Old Bridge, and is able to travel around the world.  Imagine that!

ERIC

Wii are Human Movement Specialists?

As many of you are aware, the APTA has recently undertaken a strategic planning effort, which we have previously blogged about here (and are big proponents of its getting done). However, there is some early feedback about intentions to brand PTs as practitioners of choice for "human movement disorders" rather than using plain language that consumers and payers will actually understand. Think about it. Go ask 20 of your neighbors what a "human movement disorder" is and if they've ever had one. It's rather silly actually.

I don't want to be too critical until we see the final version of the strategic plan, but I will confess to getting that sickening feeling again that we're about to cave to a vocal minority so that we can be all things to all people and not offend anyone with the use of practitioners of choice for “musculoskeletal conditions” terminology (neuromusculoskeletal works well too)…never mind that’s a phrase that resonates wildly with consumers and payers.

If we are correct that "human movement" is about to be the centerpiece of our brand (I am hoping for a bad dream), only PTs can stare an epidemic of musculoskeletal conditions like LBP in the face (LBP accounts for 2% of all physician office visits…only routine examinations, hypertension, and diabetes result in more office visits) and try to carve out a new nebulous term that says our problem is actually human movement disorders. What is the ICD-9 code? Does it lead to sexual dysfunction?

All the while, the cost of managing LBP increased 65% (adjusted for inflation) to $6096 in 2005 compared to $4695 per case in 1997, outpacing every other rate of increase in health care. Yet our problem is "human movement"?

A marketing campaign around "human movement" will be difficult at best. We need Branding 101 to get enacted here quickly (Felicity, have you started yet?...we need you to save us from ourselves!). "Human movement" is analogous to watching the typical business owner market to themselves...mostly clueless about the customer and what our brand needs to mean to the customer.

Unless we come to our senses, here are some possible brand tag lines for our "human movement" campaign.

1) Wii Are Human Movement
2) Got Human Movement?
3) PT: For When Your Movements Are No Longer Human
4) Absolutely, Positively, Human Movement
5) PT:  The Missing Link in the Human Movement

We will also need to revise our top diagnoses as seen by APTA to the following:
1) Blackberry Thumb
2) Back Pack Pain
3) Human Movement Disorder

For all three, the preferred treatment is Wii Therapy.

Ok, enough ranting here, and we welcome anyone from APTA to suggest we're way off base (and pray dearly that we've got this one completely wrong). Regardless, we have to get the economics right on this one. At the current rate of decline in reimbursement, and considering the 5% per year decrease projected for Medicare, by the year 2020, we will be an organization of volunteer "human movement specialists" who are asked to pay dues for the privilege of working for free....what a deal!

What we need is a major marketing campaign that targets real direct access for real conditions with which payers and consumers identify, LBP being the biggest one. We can only hope that common sense will prevail.

Just an initial reaction. Your thoughts?

The EIM Team

Consumer Reports Gets It

Consumer Reports gets it when it comes to spinal manipulation