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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

Glad the OMB reads the New Yorker

I read with great interest this blog post from the Office of Management and Budget’s director Peter Orszag about tough questions from healthcare including how expansion will be paid and what types of innovation needed to be pursued.

Thankfully, Mr. Orszag not only read Dr. Guwande’s great article regarding the excessive cost of healthcare in McAllen, Texas, he pursued additional information as well.  Why does McAllen spend almost twice the national average per medicare enrollee ($15,000) and almost $3000 more than their per capita income? Overutilization driven in large part by physician self-interest particularly their “business” interests.  There is also no doubt that overutilization is also driven by defensive medicine and aggressive attorneys coupled with a fee for service system that encourages more over better.

Mr. Orszag’s blog lists categories of innovation that will be part of changes including IT, “effectiveness” research, prevention and wellness, and changes in incentives that assures best care and not more care. 

My hope is that as PT’s we don’t get sucked into trumpeting ourselves as the “prevention and wellness” profession.  Let’s not kid ourselves, that would not position us in a major way in reform and attempts to do this should be challenged.  Instead, we ought to push a proven model of PT’s as important provider via extenders in musculoskeletal medicine.

If we are to put an additional 50 million people in the system, we need proven models and deregulation that allows PTs to be used as force multipliers as the current system due to physician shortage cannot handle this additional load.  We ought to be trumpeting the exemplars of PT-namely the US Military System as THE model for healthcare.  We don’t need to look to socialized countries or any other “experiment”-the best example is right in front of us.

Military medicine works off of the theory that there are too many people who need care and not enough providers.  PT’s have been providing direct access, primary musculoskeletal care for years in the military settings for both active duty, retirees, and dependents.  In some cases they are granted prescriptive authority for both meds and imaging.  It’s a system that works in large part because the government absolves themselves of all the rules they place on us in the medicare system.

As debate unfolds, be leery of the trap to push us forward as “wellness and prevention” experts. Our best position in reform is our efficacy, cost-effectiveness, and expertise is in musculoskeletal medicine.

Thoughts?

larry@physicaltherapist.com

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Healthcare 2.0

For a fascinating read on various potential reform measure, strongly suggest you read From Volume to Value, a publication of Network for Regional Healthcare Improvement (NRHI).

It raises some strong arguments and potential solutions for various solutions in an attempt to get away from a fee for service system bent on procedures to producing outcomes.

The most relevant examples for PT include two examples that really are offshoots of capitation (they refer to as Capitation 2.0) including Episode of Care and Condition Specific.  These examples try to mitigate the huge traditional risk component in capitation.

The Episode of Care example although not new is one whose time may be coming given lots of momentum at the federal level.  The easiest case to think of would be to reimburse a hospital for the entire chain of events-pre/post surgery, the surgery itself, prosthesis, rehab, etc.  The reimbursement from the insurance company is determined by the outcome-some aspect of a calculation that takes into account infection and complication rates, range of motion after rehab (yikes!), with some acceptable outcome instrument playing a role.  This “episode of care” capitation is highly dependent on integrated systems working together.  This poses some rather interesting questions and dilemmas given lots of systems unfolding their integration attempts over the last several years due to financial viability (hospitals unloading their home health agencies).  Where does private practice PT fit into this?

The second example of Condition Specific certainly makes intuitive sense.  A primary care physician is paid for managing a patients diabetes throughout a defined period of time (perhaps years).  A global payment is made, a patient’s monitoring and tests are part of that fee, and outcome goals that meet certain parameters (e.g. blood level of hemoglobin) may result in a bonus.

Would this work in garden variety low back pain?  A primary care physician or PT is paid for non-operative care to include defined outcomes? How can we best play in this game?

There is an enormous effort on cost of care and episodic care. Might just become the newest rage and buzzwords as the “solution’ to healthcare.  Stay tuned.

larry@physicaltherapist.com

Slimebucket Millionaires

or at least they are trying to be.  The gems from MDPTpartners are now resorting to mass emails to try and lure unsuspecting PT’s into their POPTS game.  You just have to love their Major Headlines-“You possess and industry called physical therapy that you are not being compensated for. Let’s change that today!!”

How they got tons of PT’s email addresses is beyond me but test assured I have little confidence in their “unsubscribe feature”.  Their ending email blast includes this bizarre note:

TAKE ACTION - Doug recently told me a shocking statistic.  His average telephone conversation with a physician is 15-20 minutes with 90%+ ending in an agreement to move forward.  His average conversation with a PT is one hour with 50% actually doing something within a month.  The problem is that the physician tells Doug whom he wants to work with so by the time the PT has finally decided to move forward, the physician has a contract and is seeing patients, your territory is taken and you are shut out. I urge you to take action to assure a secure and profitable future.

I haven’t seen a sham this good for PT’s since some unscrupulous PT’s in Kentucky as a method to affirm their credibility while soliciting doc deals formed the Ethical Physical Therapy Association which sounded legit to many docs looking to make a few benjamins in the PT business.

Although there are many outside of the PT world doing the same thing, it should be duly noted that these are PT companies aggressively seeking doc deals.

larry@physicaltherapist.com

Comparative Effectiveness Research-Great Opportunity for PT

What is being hailed as a victory for drug companies who made sure somehow to insert into the final bill, should actually be a super opportunity for us in physical therapy.  Remember, our EIM mantra: “you have drugs, you have surgery, or you have us”. Comparative effectiveness research could suggest that based on significantly lower costs and less potential adverse effects, interventions that we provide for musculoskeletal conditions can come out on top-a boon for us. 

For those of you interested, a good analysis of how language for this bill was resolved can be found here at Health Care Policy blog.

From the "American Recovery and Reinvestment -- Conference Report," page 157 of Division A:

"That the funding appropriated in this paragraph shall be used to accelerate the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies through efforts that: (1) conduct, support, or synthesize research that compares clinical [emphasis added] outcomes effectiveness, appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, and other health conditions..."

From what I can tell, this type of research aims at finding the “best bang for the buck” for any given health condition.  Yes, lots of questions about methodology come to mind including that fact that a lot of this research is based on analysis of chart reviews but undoubtedly this is an opportunity.

Now, we need leadership from the clinical scientists within the profession to stand out and undoubtedly support from all through funding, including strong support to the Foundation for Physical Therapy.Perhaps this is just the type of “change” we need to propel and get us really Moving Foward.

Thoughts?

larry@physicaltherapist.com

 

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Christmas Shopping, Consumers and Options

  Pain and expectations go together.

While in a mall outside of Philadelphia this last weekend, I dissected "The Power to Heal."

First, this banner suggests that back pain is disabling and non-relenting.  Thank you SOO much for that contribution to fear and anxiety, Abington Memorial Hospital.

Second, seeing a surgeon will be the solution.  Uh, huh... thanks for creating an expectation that those in back pain just have to see a surgeon.  Sure, let's keep the cost of care soaring.

Third, surgery provides quick results.  Evidence doesn't suggest this, but kudos for planting that seed to enhance the placebo aspect of surgery.

This wasn't the only banner suggesting surgeons or surgery as an option for various conditions.

The shoppers at Plymouth Meeting Mall need to have other options and more realistic expectations.

Can 2009 introduce a different expectation... the Best First Choice?

Photo by Selena

Selena

If There Was Ever A Time for PT's to Be The Change....

It is now. 

According to this article in Amednews.com, the lack of primary care docs leads to worse health care outcomes and higher costs due in large part to population aging and demands on health services.

Physical Therapists should be heavily engaged in this challenge as the cost-efficient provider for direct access in musculoskeletal conditions as The Best First Choice.

This is not a new concept.  We have blogged about it multiple times including here, here, here,. 

We have evidence, example (e.g. US Military), and demonstrated cost savings.  We also have a new Presidential administration desirous of input on changing the health care system.

If we are not careful, we will lose this opportunity to nurses who are are already moving in a direction we should be aggressively headed.

It will take leadership by multiple parties within our profession.  It will take strategy, marketing, lobbying, and collaboration.  Do we have what it takes?

It was Gandhi that said, “Be the change, you want to see in the world”. 

The best opportunity that we have ever had is occurring during this most trying time in our economy.  Can we get it done?

Thoughts?

larry@physicaltherapist.com