A Solution to Costly Ineffective Musculoskeletal (MSK) Care

ED SCOTT, PT, DPT, OCS April 10, 2014

President and Founder Premier Rehab Indiana, Inc.

OUR CURRENT STATE: The Broken System

Are your costs of care lower or higher?

Presentation Objectives Show evidence that the current system

does not provide value to consumers of healthcare

Debunk some myths about (MSK) musculoskeletal care and WC (Work Conditioning)

Show consumers (employers) where cost savings and improved value can be realized

NO BANG FOR THE BUCK

According to the Bone and Joint Newsletter: back pain imposes a terrible burden of

disability and costs, and one that is all too often exacerbated rather than relieved by

medical management

- Albert Camus (Nobel Prize recipient ’57)

“Without work all life goes rotten.”

Evidence-based medicine states…

A productive life includes work Keeping people off work is likely counterproductive Early utilization of physical therapy including manual

techniques and education is effective

CAUSING DISABILITY…”MY DR/THERAPIST TOLD ME….”

Gordon Waddell, M.D. infers that back pain

does not disable people- what they are told not to do does

Entities that keep people off work, because they say it “hurts to do it” cause disability and do harm to patients

Warning: Unemployment or extended time off work may be detrimental to your health!

If this were a warning would physicians prescribe it?

Work Restriction Reasoning

Restrictions should be based on:

Risk and Capacity NOT Tolerance

IS IT A RISK ISSUE?

IS IT A TOLERANCE ISSUE?

Certifying Disability 41% of physicians surveyed were pressured to write

unwarranted work excuses When primary care physicians could not provide

medical justification for excusing a patient from work, a work excuse was issued 87% of the time

Half of physicians surveyed were willing to exaggerate clinical data to obtain disability certification for patients they felt deserved it.

CDC Reports in 2002 Musculoskeletal symptoms are the most

common reason for outpatient department visits

Musculoskeletal (MSK) Knowledge A basic musculoskeletal knowledge exam

of 25 questions was developed and validated by orthopedic and internal medicine medical school chairpersons

They set a passing score of 73.1% and

validated the test by all 128 medical school chairpersons of orthopedics or internal medicine

Test Results The test was administered to 334 medical

students, residents and staff physicians

FAILED THE BASIC MUSCULOSKELETAL COGNITIVE EXAMINATION

79%

More on the previous slide The original test was called a “Competency

Examination” After 82% of 85 residents failed to get a

score of 73.1% (a high D or low C): They changed the name to: “Cognitive

Skills Examination” Orginators of the exam found about ½ of all

medical schools did not devote 1 hour to MSK

Medicalizing a non-medical problem “..the best doctor is he who recognizes

diseases and knows how to treat them, and he who recognizes symptoms that are not based in disease and knows how to avoid treating them.”

Nassir Ghaemi, MD, MPH 2011 Medscape

Overuse of Imaging - Medicalizing Authors state their findings seem to indicate

that imaging is often done based on clinical practice settings and incentives as opposed to clinical findings repeatedly indicated as an “indication for imaging”

WHO HAS EXPERTISE IN MSK? Outcomes were measured in this randomized

trial, orthopaedic PTs are as effective as orthopaedic surgeons in the initial

assessment and management of (MSK) patients and generate lower costs

PT AS MSK EXPERT “Research actually shows PTs know more

about the musculoskeletal system than most MDs do.”

CDG, M.D. 2011

THERAPY IS THERAPY RIGHT? NOT!!

CASE REPORT MVA (Motor Vehicle Accident) May 2011

46 PT sessions with modalities such as electrical

stimulation, and exercises for low back pain

Off work November, 2011 (waitress); NO PAIN Returned to work December – pain returned

Case Report (cont) Preventing Disability

The presenter discussed with her that if she was pain free for the month while off work, why would she think that a return of pain was attributable to the accident and not just soreness from going back to physical work she had not done for a month?

I told her I would not recommend any restrictions in her activities at home or at work or more therapy simply because it may "hurt".

To the presenter’s knowledge she returned to work and was seen only one time by the presenter.

Manual Therapy Works

In a systematic review the authors

concluded that manual therapy and exercise are superior to exercise alone.

Effective PT Should include Manual Therapy

MANUAL THERAPY WITH ADDITION OF EXERCISE

IS PROVEN BETTER THAN EXERCISE ALONE FOR MOST MSK PROBLEMS

JAN – JUNE 2009. SPINE PATIENTS RECEIVED AN AVERAGE OF 1.27 VISITS WITH DR. SCOTT WITH DISCHARGE TO NORMAL WORK

TESTIMONIALS COL. GLENN M. SCOTT JR., USAF-R

CHERYL BURKHALTER, R.N.

MAGGIE HENRY

IS EVIDENCE BASED CARE PROVIDED CURRENTLY IN YOUR

SYSTEM?

“if it (what we currently do) is medicine, it is

the medicine of the believer, not the knower.”

Nassir Ghaemi, M.D. MPH

For Providers to Prevent Disability

They Must:

KEEP PEOPLE WORKING!

HURT DOES NOT MEAN HARM

Number one Reason for Medically Unnecessary Time Off Work

Treating Physician is unwilling to force a

reluctant patient back to work

EDUCATION IS KEY TO SUCCESS Research shows EDUCATION OF

HEALTHCARE CONSUMERS (this includes employers) AND PROVIDERS

IS NECESSARY FOR SUCCESS

CONSUMER EDUCATION EDUCATING THE CONSUMER OF

HEALTHCARE AND THE “BILL PAYERS” IS ESSENTIAL

AS LONG AS PROVIDERS GET PAID FOR THE UNNECESSARY THERE IS INCENTIVE TO CONTINUE

PERVERSE SYSTEM

HEALTHCARE SYSTEMS FREQUENTLY CONDONE AND REWARD PROVIDERS FOR IMPROVED PRODUCTIVITY

NOT IMPROVED OUTCOMES

Type II Malpractice? Def: Doing the unnecessary

superbly

Actual documentation from a chart

when prior authorization (pa) for shoulder surgery sought:

“Anthem (insurance company) no pa needed as long as medically necessary per Ronnie”

CASE MGMT OR DISTRIBUTING WEALTH!

Who makes any determination of, or actually checks for medical necessity and what qualifications do they have to do so?

Is this function really adding anything of value to the patient or the employer paying the bill?

Prior Authorization Considerations Are the records and examinations of all

parties considered prior to authorization? Is the evaluation/recommendation of the

orthopedic therapist whose proven track records considered?

Is it routine to request an opinion of someone that does NOT have a financial interest in the procedure/intervention requested?

SLAP SOME PAINT ON IT AND SELL IT!

MANY PA “SCHEME(s)” ARE A HOAX Many times authorization is granted based

on patient/employee complaints rather than frank objective findings.

Many times the requester has a financial interest in requesting authorization

TYPICAL PA REQUEST “The patient has failed conservative care

including NSAIDS, injections and therapy and therefore I have recommended (surgery)”

TRANSLATION: The patient/employee continues to c/o pain (Remember: is it a tolerance issue?)

Surgeon’s argument: “But they have abnormal findings on the MRI” – (but so does many people who have no symptoms!)

Solution for Employers Ask another (non-affiliated) surgeon for his

opinion with the caveat that he will NOT be granted authorization to do the surgery – an opinion or consultation is all that is requested.

This removes the financial incentive.

Case Report: Ignoring Information for PA

Injured worker is seen by Occupational Medicine Physician

MD documents 11/5/13 patient cannot lift arm:

ROM (range of motion) in the affected shoulder is greatly decreased; ROM is accompanied by pain at extremes. He has flexion to about 30 degrees and now abducts only to 70 degrees.

Case Report: Ignoring information for PA

PT documents 11/15/13:

Patient can fully flex shoulder/arm

overhead. Patient has good strength of rotator cuff

muscles

Case Report: Ignoring information for PA

On 11/27 PT documents: Patient has full (passive) motion in the L

shld. On 12/3/13 MD documents: Range of motion in the affected shoulder is

still quite limited on my exam An MRI is ordered and authorized

despite these discrepancies

ROTATOR CUFF TEARS Rotator cuff tears are common and are

frequently asymptomatic. Rotator cuff tears demonstrated by (MRIs)

may not be responsible for the symptoms. It is important to correlate radiological and

clinical findings in the shoulder.

CUFF TEARS MAY BE ASYMPTOMATIC

…..subject population……..had never sought medical advice for a shoulder problem and all were asymptomatic…..

results indicate that treatment of suspected rotator-cuff problems should be based on clinical judgment

reliance should not be placed on MRI results.

Torn rotator cuffs need surgery- NOT

One study emphasized the potential hazards of the use of the MRI as a basis for recommending surgery, in the absence of associated clinical findings.

EMPLOYER RECOURSE Seek an opinion from a considered expert that

has no financial interest in the requested procedure/intervention.

Always consider the examination findings of the orthopedic therapist

Consider that many if not most imaging findings of abnormalities are quite common and MAY not be causing symptoms;

Job satisfaction (tolerance) may be the main problem

EMPLOYER RECOURSE

Ask the person recommending a test or intervention if it has been proven to be or shown to be effective?

Example Questions Is the FCE valid (does it measure what it is

purported to?) or reliable (are the results reproducible?)

What is the success rate of returning individuals to work of the provider of WC (Work Conditioning) or WH (Work Hardening)? Does the person ordering this know if these are successful?

Research Evidence on WC The effectiveness of physical conditioning

as part of a return to work strategy in reducing sick leave for workers with back pain, compared to usual care or exercise therapy, remains uncertain.

The effectiveness of physical conditioning programs in reducing sick leave for workers with back pain remains uncertain.

More Evidence of Effectiveness of WC

Currently there is no or insufficient evidence that GA (Graded Activity) results in better outcomes of patients with non-specific LBP.

Physical conditioning programs that incorporate a cognitive-behavioral (i.e. education) approach reduce the number of sick days for workers with chronic back pain when compared to usual care

More WC Evidence Graded activity was more effective than

usual care in reducing the number of days of absence from work because of low back pain.

What does this mean? That the usual care is the problem and WC

has not been shown to be the “bail out” that will get people back to work when the treating physician or therapist is reluctant to send them back to work because of tolerance issues, instead of sticking to generally measurable metrics of risk and capacity.

Case Report on WC Pt had rotator cuff surgery June Pt had 58 therapy visits and continued on

restrictions 6 months after surgery Surgeon ordered WC Employer denied payment for WC

Case Report on Resolution of WC Presenter was consulted Presenter toured facility to see actual work

requirements Presenter set up ramp program to return to

regular work in one month. Result: Return to regular work in one

month as planned

Back Pain Treatment Increasingly Ignores Clinical Guidelines

Despite published guidelines that call for

physical therapy or medications such as ibuprofen or acetaminophen for first-line management of most back pain, other treatments such as imaging, narcotics, and referrals to other physicians have increased.

BACK SURGERY Rates of back surgery in the United States

are the highest in the world, and continue to rise steadily. More recent increases have primarily been observed in rates of lumbar fusion

COSTS GO UP, WORSE OUTCOMES

Unbelievable Yet True!

271% increase for epidural steroid injections 1994-2001

423% increase for opioids 1997-2004 307% increase in MRIs 1994-2004 220% increase in spine fusion 1990-2001

DeyoRA et al JABFM 22 (1); 2009

A REALLY BIG $ PROBLEM More than 10% of visits to primary care

physicians (PCPs) relate to back or neck pain, representing the fifth most common reason for all physician visits and accounting for approximately $86 billion in health care spending annually.

THE PROBLEM GETS BIGGER Indirect costs related to lost productivity

amount to an additional $20 billion per year, which likely is an underestimate because the prevalence of chronic back pain may be increasing.

From the journal SPINE Evidence-based guidelines, when followed,

have had some positive impact of the clinical management of LBP, including better functional outcomes, reduced health care utilization and lower health care costs.

Yet there is a strong body of evidence suggesting a low level of adherence in daily clinical practice.

Over Use of Imaging

Primary care physicians are making a

significant amount of inappropriate referrals for CT and MRI

J American College of Radiology 2010; 7

Duke University 500 lumbar spine MRI results ordered by

two groups of doctors One group had a financial interest in the

imaging equipment and the other did not

Duke Results

86% more unnecessary MRIs in the

financial interest group

MANY FALSE POSITIVES

TREATMENT BASED ON IMAGING MAY NOT BE APPROPRIATE BUT IS USUALLY PROFITABLE

“I GOTTA DO SOMETHING”

Translation: the mere presence of findings on MRI makes both patients and doctors feel obliged to do something even though that something is usually unwarranted.

The Back Letter

ARTHROSCOPIC KNEE SURGERY

A STUDY SHOWED AS HIGH AS 65% FALSE POSITIVES IN KNEE MRI FOR MENISCUS DAMAGE

SAME AUTHORS CONCLUDED 37% THAT HAD ARTHROSCOPY DID NOT NEED IT

Case Report A 30 something male seen after knee injury MD sends him for strengthening Presenter reported he had an ACL tear and

lax secondary restraints MRI confirmed tear. No bone bruise seen Orthopedist saw bone bruise. Was there a financial incentive to see a

bone bruise (indicates acute injury)?

USE PROVEN AVAILABLE RESOURCES

DECISIONS, RECOMMENDATIONS AND INTERVENTIONS BASED ON EVIDENCE

ORTHOPEDIC PHYSICAL THERAPIST

FOR MUSCULOSKELETAL PROBLEMS

PHYSICIAN FOR MEDICAL PROBLEMS

-- GEORGE PATTON

"If everyone is thinking alike, someone isn't

thinking."