The influence of patient choice

“Approximately $85 billion are spent annually on spine-oriented conditions, and an additional $10 to $20 billion are attributed to economic losses in productivity…Per-patient costs have increased by 49% from 1997 to 2006.”

Spine related issues cost our country about $1 Trillion over the course of a decade. Seeing as how we are dealing with a pandemic, people now have a better understanding what $1T can do for the country.

It can give each person thousands in financial relief. It can give small businesses hundreds of thousands in relief.

The number seems arbitrary until you actually see what a Trillion dollar bailout looks like.

If we can reduce the impact of back pain on society, we could keep this money in the economy because there wouldn’t be lost productivity, out of pocket spending and other expenses that come with back pain.

Healthcare would forever be changed if we can reduce the economic impact of back pain, as it is the most prevalent issue seen in outpatient clinics, many emergency departments and most primary care physician offices.

There would be so much opportunity to actually focus on maintaining a healthy population instead of trying to solve a pain/disability problem.

“despite the rising costs, there has been no real improvement in terms of disability or reduction in the proportions of individuals who report back or neck pain.”

This is a little bit of a controversial fact for me. Our ability to treat back pain through classification has improved over the years. For instance, a recent study on downstream costs shows that when using MDT there is fewer follow-up visits and extensive diagnostics required.

I don’t think that we will ever stop people from experiencing pain, back pain or any other locations. People experience pain. This is a fact. Pain can be a good sign to keep us from doing things that create pain in the first place. The problem, in my opinion, is when we allow pain to prevent us from doing things that are considered a normal part of life.

For example, most experience pain when touching a hot stove. This can be used as a warning signal that hot stoves are dangerous.

Unfortunately, many experience pain when bending forward. The same logic applies and some believe that they are actually creating harm when bending forward, so it’s avoided altogether.

This is where I believe a good PT can be worth his/her weight in gold. Teaching a patient to return back to normal activities that the patient previously believed to be dangerous could increase the patients quality and possibly quantity of life.

I now want to address the rising costs of treating pain. The next unfortunate issue is that I personally know practitioners that are so out of touch with current research that they continue to treat patients as if it is 1980. We wonder why, as a whole, we are no better at treating patients.

Why do you think this happens?

One reason is that healthcare is a business.

There’s a ton of conspiracy theorists out there that believe the government is hiding the cure for cancer so that the businesses that treat cancer can continue to make money. For some reason this same conspiracy hasn’t made its way down to back pain.

I’m not sure if you saw the amount of money spent on back pain, but if not then go back up to the top of the post.

There’s big money in back pain.

Why should providers want to get you better faster?

In all honesty, I think the providers want you to get better faster. The providers don’t typically make much less if you get better faster.

The business on the other hand stands to lose a lot of money if the patient gets better at a faster rate.

I’ll speak specifically to physical therapy and use real numbers.

On average a clinic with 2 PT sees about 10 new patients per week. Let’s just say that 8 of the 10 are for some version of spine pain.

This would mean that on average we are seeing 400 new cases of spine related pain in a two person clinic per year.

On average, the reimbursement per treatment session in IL is $95-$100 per session.

If the business asks (more like demands) that a PT keeps the patient for 13 sessions, where’s the therapist with less supervisory demands sees the patient for 8 visits, there is a major difference in the overall income for the clinic.

Clinic 1:

400 (new patients) x 13 (visits)= 5,200 visits

At $95/visit

5,200(visits) x $95(per visit)= $494K

Clinic 2:

400(new patients) x 8(visits)=3,200 visits

At $95/visit

3,200(visits) x $95(per visit)=$304K

Are you starting to understand the problem?

The clinic that requires PTs to see a patient for a specific number of visits stands to generate an extra $190K. This is an example for a two therapist clinic.

Multiply that by the hundreds of thousands of PTs in the country treating back pain and you see how the costs are artificially inflated.

Until insurance companies cut back on what is reimbursed, we will not see a change in practice. What we are seeing insurance companies do is a step in the right direction, bu I personally believe that they are doing it incorrectly.

Right now the insurance companies are giving us typically 8-12 visits that are to be used over the course of 6-8 weeks.

What I would like to see is an insurance company give us a stipend of a few thousands of dollars to care for that one patient over the course of the year. Meaning any problem that occurs with that particular patient is our responsibility to rehab. We become accountable for that patients health.

We are seeing this with some Medicare Advantage Plans, and it seems to be effective at countering the rising costs of healthcare.

Until a drastic change in how we get reimbursed happens, we will continue to see the numbers rise like they have.

I just don’t think that the changes that have happened, restricting the number of visits, is enough to make companies take responsibility for actually helping patients.

“The estimated proportion of persons with back or neck problems to self-report physical functioning limitations increased from 20.7% to 24.7% from 1997 to 2005, suggesting that current care models may be insufficient.”

I have personally seen patients reporting increased disability with time.

Part of what has to be considered is “how many of these individuals reporting disability also have secondary gain issues?”

Meaning, how many people reporting increased disability are actually receiving disability payments?

Secondary gain issues would have to be considered a limiting factor when reporting these numbers.

The next aspect to be considered is the affective component of the impairment. Meaning, how many people are experiencing increased disability due to the environment they spend their time and the situations they surround themselves.

It’s like the opposite of herd immunity. I’ve been part of many FB groups specifically designed for support, but the groups offer anything but support. These groups offer misrepresentation of diagnoses and prognoses. Many people looking for support and assurance are met with information about lifelong disability, surgical options and nocebo language.

There’s more to disability than pain.

A persons belief about pain has an impact on disability. We know this.

We really need to look at changing the narrative about back pain.

“Clinical practice guidelines for primary care management of spinal conditions generally suggest initial management strategies of self-care and nonsteroidal anti-inflammatory medications. Referral to specialist, including physical therapist or for diagnostic imaging is only encouraged for those who failed to respond after period of watchful waiting.”

This is part of the problem. Instead of stratifying the patient based on risk factors for developing persistent pain, which I’ve written about one tool previously, they are treating all back pains similarly.

Some patients will get better on their own without any treatment.

Others would benefit from early treatment.

The medical system has to do a better job of separating these groups in order to maximize outcomes and reduce disability numbers.

“recommended best practices based on such clinical practice guidelines are to avoid bedrest, to use opioid medications for a limited time, and to obtain magnetic resonance imaging only for specific presentation of radicular symptoms.”

This seems very basic.

Unfortunately, these aren’t necessarily followed. I have many patients, over my career that are opioid dependent. There is research showing that long term opioid usage can actually increase a person’s sensitivity to pain. Think about that, medication that initially makes a person unable to sense pain, over time makes a person feel more pain (either frequency or intensity).

I believe that the idea that imaging should be minimized until needed has be adopted more so than the short term usage of opioids.

I rarely see patients coming into the clinic for an evaluation that received an MRI prior to physical therapy. Part of this has to do with insurance companies not approving MRIs until conservative care has been attempted. This has to be commended.

Now we just need our profession to stop looking at patients like an ATM and start to see each case as one that could go to surgery if we don’t make progress.

We have to see the months that the patient would be unable to work and function. We have to employ empathy.

The state of the profession currently sees patients as widgets to be accounted for in productivity measures.

Again, this needs to change in order for us to have an impact on the disabling mentality that is growing with regards to back pain.

“… alternative care models offering direct access (The ability to seek and receive the examination, valuation, and intervention by physical therapist without requiring physician referral for legal or insurance coverage) to physical therapy have suggested fewer days of care and lower costs.”

Looking purely at costs, direct access has the potential to save insurance companies and patients money. This savings would come at the expense of the physicians, hospital systems and emergency departments.

But how you ask?

As it stands, patients would require a referral in most states to be evaluated and treated in a physical therapy environment for longer than 4 weeks. Because of this, a patient would need to go to a physician in order to receive a referral for physical therapy. Each time the patient sees the physician, the costs is about $80.

If PTs has direct access, which in my mind doesn’t just include the ability to be assessed and treated by a physical therapist, but also consists of having that particular patient’s insurance pay for the assessment and treatment, then we would have fewer trips to the emergency department, quick care or physician.

This would save money immediately for the healthcare system and saves the patient time. Instead of waiting to get into a physician and then waiting to see the PT, the patient could walk into the PT office and be assessed within 24-48 hours.

“The majority of the 447 patients included in the analysis chose traditional medical referral (61.7%).”

This is interesting for me to navigate. The group that chose to go the route of direct access ended up saving about $1,500 in total cost of care. This number is misleading though because it didn’t take into account the amount of money that the patient actually paid out of pocket.

For instance, in a 90%/10% coverage plan, the patient would have only paid an extra $150 out of pocket (assuming the deductible was met). That’s a large difference from the patient paying an extra $750 if the patient has an insurance that pays 50%.

Because this $1,500 can vary patient to patient, I’m not sure if it is a good metric to use because it really tells us how much money we are saving the insurance company, instead of telling us how much money we are saving the patient.

I understand the argument that if we save the insurance company money, then we would save the patient money on a lower premium, but I just don’t believe that we will make enough of a dent in healthcare costs to ever drop premiums. It is a business after all and the scenario I more likely see is the business pocketing a larger profit for the money we save them.

This brings us to the next topic : why would patients choose to go to see a physician first before going to PT as a direct access visit?

I think that this would make a good quantitative study to determine what are the factors that correlate with seeing a physician first for back pain prior to seeing a PT.

The other questions to be asked are what would make one choose a chiropractic physician, naprapathic doctor, accupuncturist, massage therapist or physical therapist for specific ailments?

In the end, we know that we have the potential to save the patient money if the patient chooses a direct access (walk into the clinic off of the street) when compared to seeing a physician prior to receiving a referral for physical therapy. Because a majority of patients in this particular study still chose the physician first, there must be other issues in play as to why patients aren’t choosing direct access OR the patients aren’t aware that we could actually save them money.

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