Jun 1, 2016 | Insights
Many states currently restrict the ability of patients to see a physical therapist as their first point of care. What are the risks—and what are the benefits—to PT as direct point of access?
Access is a big issue for savvy consumers selecting a plan in today’s healthcare marketplace. The ability to see specialists and non-physician healthcare professionals without a referral can be the deciding factor when comparing insurers or choosing between an HMO and PPO.
However, in some states, direct access to physical therapy treatment remains a legislative issue.
According to the Health Care Cost Institute, current state laws restricting direct access to physical therapy include:
- Requiring a physician referral prior to seeing a physical therapist
- Time limits on how long a patient can be seen by a physical therapist before requiring a physician visit
- Education and/or credential thresholds for physical therapists to see patients directly
These restrictions have implications for patients, physical therapists nationwide and the healthcare system at large.
Disempowering the Physical Therapist
Those opposing direct access to PT have contended that physical therapists lack the education needed to recognize infections, fractures and other serious medical conditions. They state that because physical therapists do not order diagnostic tests and make medical diagnoses, they require medical oversight.
Physical therapy is a highly regulated profession across all 50 states, requiring both formal education and clinical training to analyze a patient’s condition and assess his or her PT needs. Physical therapists are trained to recognize when it is appropriate to safely and effectively treat a patient – and when signs and symptoms indicate that the patient should be referred to another healthcare professional.
Much like physicians, physical therapists look for warning signs in the physical exam and patient history that would prompt further testing, as outlined in the Guide to Physical Therapist Practice. When there is concern of a serious nature, the problem would be deemed outside the PT’s scope of practice, and a referral to a physician would be in order.
Impacting Utilization Rates
In turning this argument on its head, one may surmise that because physical therapists do not have the same medical privileges as physicians, seeing a PT first may result in lower utilization of unnecessary medical services. And they would be right.
According to a study by Frogner et al that compared patients suffering from low back pain (LBP) who first saw a physical therapist versus another provider, several positive utilization outcomes were associated with seeing a physical therapist first, including:
- Significantly lower costs across almost all settings (with a few exceptions)
- Significantly lower probability of having an emergency department (ED) visit
- Lower imaging rates
Notably, patients with LBP who first saw a physical therapist also had a lower probability of opioid prescription, which is a likely outcome for patients who visit an emergency department with persistent back pain. It should not be surprising that concurrent with an increase in back pain-related opioid prescriptions, EDs have seen an uptick in drug overdoses. Research shows that opioids do not significantly improve health outcomes, but are associated with an increase in mortality risk.
Expanding Access, Addressing Cost
Overutilization of medical services not only has implications at the patient level; it further clogs a strained healthcare system struggling to control costs and improve access to critical medical care.
Healthcare costs related to LBP, for example, continue to outpace non-LBP expenditures, amounting to $90.6 billion in direct costs and $19.8 billion in indirect costs. As we reform our national healthcare system and face a shortage of primary care physicians, states must look for new ways to offer healthcare access to their citizens while controlling cost. One way is to expand access to non-physician healthcare professionals, such as physical therapists.
In the Frogner et al study, it was found that patients who had PT first saw significantly lower care cost totals compared with those who had PT later or no PT (controlling for patient characteristics and distance between patient and provider). Although there was not a significant difference in pharmacy costs, patients who had PT first accrued lower physician and outpatient costs overall. These patients were also less likely to use imaging services, which, when used prematurely, has been found to lead to higher costs without significant health benefits.
Research continues to be done to support the efficacy and benefits of direct PT care. Over recent years, limitations found in state laws have eroded; however, many unnecessary barriers to direct PT care still remain.
By amending outstanding legislative restrictions, we can empower physical therapists to exercise the extent of their training, provide patients with less expensive and more timely care, and offer an additional entry point to an overburdened national healthcare system.
Bibliography
American Physical Therapy Association (APTA) (2016, April 15). Direct Access at the State Level. Retrieved from www.apta.org/StateIssues/DirectAccess/
Direct Access: Where’s the Risk?
Frogner, B. K., Harwood, K., Pines, J. M., Andrilla, H., & Schwartz, M. (2016). Does Unrestricted Direct Access to Physical Therapy Reduce Utilization and Health Spending?
Apr 26, 2016 | Insights
Advanced imaging is a popular – and expensive – first course of action for patients with lower back pain – but does it always pay off?
Approximately 80 percent of adults experience some form of lower back pain (LBP) in their lifetime. It’s so common, in fact, that it is discussed at 1 in every 17 primary care visits. Such prevalence has prompted an unprecedented focus on the diagnosis and management of LBP patients. Yet despite our increased understanding of back pain, LBP-related costs have increased, with the United States spending more than $86 billion on direct LBP-related costs in 2005, and $1500-$2000 per individual in direct costs.
Conservative Care as First Treatment
A 2015 study published in Health Services Research (Fritz et al) sought to investigate the high cost of advanced imaging for patients with uncomplicated LBP. In particular, the research team compared the healthcare utilization and LBP-related charges of patients who received advanced imaging versus the more conservative physical therapy as the first management strategy.
In a study of 841 people who required additional care following a primary care appointment for uncomplicated LBP, Fritz and colleagues found that those who were first sent for MRIs were more likely to receive a surgical or injection intervention, require specialty care or visit an emergency department. In addition, these individuals saw LBP-related charges averaging $6,193. That’s $4,793 more than those who were first administered physical therapy.
The Psychology of Advanced Imaging
Research suggests that advanced imaging is a more costly first step and, in the absence of specific symptoms, may not deliver significant clinical benefit during this early stage of treatment (Chou 2009). So why do MRIs continue to be so common, especially given their high price tag? In the discussion section of her study, Fritz explains that the reasons often have more to do with psychological matters than lumbar concerns.
- Patient expectations: When a patient sees a primary care physician for LBP, he or she is typically looking for a diagnosis and a curative, or at least pain-relieving treatment. Many patients believe that back pain is a sign that the spine has become abnormally positioned and must be corrected or risk becoming unsound or unreliable on a daily basis. This often leads them to push for advanced imaging – and to view denial of such services as an unfavorable response. Consumer research suggests that offering an alternative to replace the broken expectation is important in these instances. Physical therapy, which is viewed as a credible form of treatment, is often an ideal and agreeable alternative.
- Labeling: Identifying and labeling the source of pain through advanced imaging can provide patients with a sense of satisfaction, but this can also lead to heightened concern – and even catastrophic thinking, a known psycho-social barrier to recovery. As an alternative, conservative clinical care (e.g., physical therapy) may be a way to avoid the negative consequences of labeling and deter additional care-seeking while, at the same time, yielding clinical outcomes similar to those who first undergo lumbar imaging (Chou 2009).
- Specialty care vs. self-care: The care-seeking prompted by advanced imaging can often lead patients down a road of specialists and procedures, rather than encouraging them to actively participate in the management of their condition. A major component of physical therapy is engaging patients in their treatment and educating them about their pain – including the fact that most uncomplicated back pain subsides over time. This approach often motivates patients to contribute to the management of their back pain away from the clinic. Additionally, it has been suggested that the self-management strategies learned in physical therapy may play an important role in long-term care and help patients avoid recurrent cases.
The study by Fritz et al reaffirms a growing body of research suggesting that while advanced imaging can be extremely valuable in certain contexts, it may not be a necessary course of treatment in the initial management of uncomplicated LBP. For the right patients, physical therapy will often prove to be an ideal alternative as the less invasive and less costly option. But perhaps even more valuable, by collaborating with a physical therapist in their own care, patients may find that the road to recovery is one they can largely walk on their own.
Bibliography
Chou, R., Fu, R., Carrino, J. A., & Deyo, R. A. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), 463-472.
Escolar-Reina, P., Medina-Mirapeix, F., Gascón-Cánovas, J. J., Montilla-Herrador, J., Valera-Garrido, J. F., & Collins, S. M. (2009). Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Archives of physical medicine and rehabilitation, 90(10), 1734-1739.
Fritz, J. M., Brennan, G. P., & Hunter, S. J. (2015). Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health services research, 50(6), 1927-1940.
Murphy, D. R., & Hurwitz, E. L. (2011). Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropractic & manual therapies, 19(1),
Optum (2014). Conservative back treatment maximizes quality and affordability. Retrieved from www.optum.com/content/dam/optum/resources/whitePapers/ConservativeArticle_112211.pdf
Zusman, M. (2013). Belief reinforcement: one reason why costs for low back pain have not decreased. Journal of Multidisciplinary Healthcare, 6, 197–204. http://doi.org/10.2147/JMDH.S44117
Mar 30, 2016 | Insights
Smart application of the telehealth trend can provide clear benefits to physical therapists and patients, but there are still some significant challenges to widespread adoption.
Imagine you’ve suffered a recent musculoskeletal injury. You’re doing at-home exercises daily, but you’re worried your form may be off. What if instead of driving into the office, all you had to do was reach for your smartphone to videoconference with your therapist?
Advances in technology—in addition to growing needs prompted by the Affordable Care Act and an aging population—have telehealth projected to grow to 1.8 million users worldwide by 2017, according to the World Market of Telehealth. Now, telerehabilitation is becoming a viable option for physical therapists who want to supplement hands-on therapy with remote offerings such as online exercise demos, workout supervision, and secure patient communication tools.
How Telehealth is Changing Physical Therapy
How could telehealth stand in for the hands-on therapy and face-to-face communication integral to successful musculoskeletal treatment? The answer is, simple: it can’t.
Not all patient-provider interactions are currently translatable to telepractice. For instance, massage and manual manipulations are undeniably in-person treatment methods (although solutions like Microsoft Kinect, which uses a 3D motion sensor to allow patients and therapists to interact in real time, may soon change that).
While telehealth may never replace therapy appointments, the accessibility and convenience of a virtual therapist visit make it an ideal option for follow-up treatment, home treatment plans, questions and answers, and consultations with specialists.
Let’s look at few of the primary advantages this method of therapy has to offer.
- Cost and time savings: The incorporation of telerehabilitation into traditional care plans may allow PTs to develop more time-efficient and less costly care models. Electronic check-ins save patients the trip to and from their therapist’s office, which can be a significant return to their pocketbook—especially in rural areas.
- Flexibility: With the ability to facilitate patient-provider interactions remotely, telerehabilitation can connect patients with hard-to-find specialists that may be located hours away. It also allows therapists to deliver care in a more flexible way, even allowing some patients who are typically seen in clinical or hospital settings to be managed in their homes instead.
- Smoother care coordination: The option of checking in with your PT from home can strengthen the patient-therapist relationship, possibly even shortening the road to recovery. Additionally, telehealth can improve communication between providers, with potential benefits including quicker screening, assessment, and referrals for patients.
While it is clear how telehealth could bolster the rehabilitation process, there are still several barriers for physical therapists who want to offer virtual support services. Current challenges include:
- Hardware/software requirements: While many of the most common videoconferencing software programs don’t offer the level of security required by healthcare law, secure, HD platforms like GoToMeeting do comply with the Health Insurance Portability and Accountability Act (HIPAA) and allow for synchronous live video streaming, screen sharing, and shared presenter controls.
- Billing and coding issues: Telerehabilitation presents some coding complexities for physical therapists as billing codes have yet to adapt to telehealth activities. Some billing codes currently exist for PT telehealth, but they are not yet the standard and can vary depending on state and by insurer. Physical therapy has not yet been cited in federal legislation regarding telehealth services reimbursement.
- Legislation and regulations: Current law prohibits PTs from treating patients who live outside of the state in which the therapist is licensed. This precludes PTs from practicing across state lines—even in a virtual environment. Both the American Physical Therapy Association and the Federation of State Boards of Physical Therapy are working toward defining and eventually altering legislation to facilitate more widespread adoption of telehealth.
Could virtual PT become a mainstream piece of the recovery process? Quite possibly. But until legislations and regulations catch up to advancing technologies and growing patient demand, we must rely on innovative physical therapists to find a way to make telehealth work within the given parameters, to demonstrate the value it delivers to their patients, and to blaze a trail for this much-needed form of support in the rehabilitation world.
Bibliography
“APTA 2014 Recap: Forging Ahead with Telehealth: A Roadmap for Physical Therapists,” last modified February 11, 2014, http://wellpepper.com/apta-2014-recap-forging-ahead-with-telehealth-a-roadmap-for-physical-therapists.
“Telehealth,” last modified September 8, 2015, http://www.apta.org/Telehealth/.
“Telehealth in PT: Expanding Possibilities,” last modified March 31, 2015. https://www.webpt.com/blog/post/telehealth-in-pt-expanding-possibilities.
“Telerehabilitation: Will Telepractice Catch On for Occupational and Physical Therapy?” http://myptsolutions.com/telerehabilitation-telepractice-occupational-physical-therapy/.
Mar 11, 2016 | Insights
Psychosocial factors play a deeper role in injury rehabilitation than originally suspected, and innovative therapies are seeing surprising success.
Research suggests that pain accounts for only 10 percent of a disability, whereas psychosocial factors can explain as much as 30 percent variance in the magnitude of a disability experience. Historically, treatment for chronic pain-related conditions included opioid prescriptions, multi-disciplinary programs or cognitive-behavioral pain management tactics.
However, it wasn’t until recently that psychosocial intervention began to gain new ground, thanks in large part to the research and methods developed by Dr. Michael Sullivan of the University Centre for Research on Pain and Disability.
Sullivan has spent the last 20 years investigating how to introduce an intervention program targeting psychosocial barriers in the rehabilitation process. The program that emerged was the Progressive Goal Attainment Program, or PGAP™.
Now new studies have illuminated the positive impact PGAP can have on clinical outcomes when combined with physical therapy.
Why has this new intervention model seen more success than previous efforts?
1. Early intervention
Research has shown that the probability of return-to-work outcomes decreases the longer an injured individual is out of commission. Similarly, recently injured individuals have a faster recovery time than those who have a chronic work disability.
In the past, patients with complex psychosocial risk were often identified only after their condition had become chronic and treatment-resistant. At this stage, the multidisciplinary interventions, in combination with repeated treatment failures, tended to produce only modest improvements – if any.
Injured workers who require physical rehabilitation typically visit their physical therapist 1 – 2 times a week for a period of weeks. These professionals are ideally positioned to assist in the early identification of psychosocial risk factors for faster intervention.
2. Integrated treatment
Traditional cognitive behavioral therapy is handled by psychologists or those with a mental health background. This has been limiting in two ways: (1) it has restrained access to psychosocial resources and (2) it has often resulted in a fragmented physiological and psychological treatment program.
PGAP—when used in conjunction with physical therapy—creates a more integrated and more efficient treatment strategy that addresses both the physiological and psychosocial barriers to recovery at the same time.
3. Activity-based therapy
Unlike traditional pain management treatments, PGAP focuses on behavior versus cognition, yielding a much more active treatment process. The first few weeks of the program are intended to establish a strong working relationship with the PGAP consultant through disclosure and validation techniques, but the focus then moves to developing a structured activity schedule. When combined with physical therapy the program focus and activity schedules encourage safe reintroduction into the workforce.
4. A focus on return to work
Unlike other rehabilitation interventions, PGAP’s main objective is not symptom reduction, but reduction of disability. Research shows that symptom reduction is not a precondition for successful return to work. In fact, an overt focus on symptom reduction may reinforce the patient’s belief that symptoms must be eliminated before work activities can resume.
In one study, the addition of PGAP to a functional restoration physical therapy program increased return-to-work rates by more than 50%, and in a sample of 70 individuals with chronic disability caused by cervical sprain injury, 75% of clients were able to resume work following PGAP completion.
MedRisk’s solution for delayed recovery cases incorporates these proven treatment strategies, combining evidence based treatment guidelines, early identification of psychosocial barriers, PGAP and physical therapy to deliver a more direct road to rehabilitation, and an improved quality of life for your workforce.
Bibliography
Sullivan,M. J. L., Adams, H., Rhodenizer, T., & Stanish,W. D. (2006). A psychosocial risk factor-targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy, 86(1), 8–18.
Sullivan, M. J. L., & Adams, H. (2010). Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiotherapy Canada, 62(3), 180–189.
Sullivan, M. J. L., Adams, H., & Ellis, T. (2013). A psychosocial risk-targeted intervention to reduce work disability: Development, evolution, and implementation changes. Psychological Injury and Law, 6, 250–257.
University Centre for Research on Pain and Disability (2013). A Community-Based Intervention for the Prevention of Pain-Related Disability [PowerPoint slides]. Retrieved from http://indep.ca/wp-content/uploads/2013/11/PGAP1.Presentation.pdf.
Feb 2, 2016 | Insights
By Kevin Basile, PT, OCS, MTC, Director of Provider Relations Physical Medicine
As more Americans postpone retirement, employers are taking steps to optimize working conditions for their employees.
Companies across the country are embracing their senior workforce, recognizing the expertise, loyalty, and mentorship experienced employees bring to the table. However, the unprecedented demographic shift has employers and payers alike wondering whether workers’ compensation loss costs will also experience an upward swing.
In 1964, baby boomers made up a staggering 40 percent of the population. Fast-forward half a century and boomers are surprising the census yet again—this time with a surge in the workforce. Between 2004 and 2014, the number of active American workers age 55 or older skyrocketed by 47.1 percent. According to the Bureau of Labor Statistics, this group’s share will increase to one-quarter of the workforce by 2024.
In 2012, the National Council on Compensation Insurance (NCCI) stated that the impact of an aging workforce on loss costs may be less negative than previously believed. In a report released that same year, the NCCI revealed that injury rates for workers age 45 and older dropped by 50 percent between 1994 and 2009, due at least in part to workplace safety initiatives.
Unfortunately, the positive trend in frequency rates was counterbalanced by an increase in severity. Rotator cuff and knee injuries top the list of workers’ comp claims among the 55+ crowd. On their own, these injuries can be difficult to bounce back from, but common effects of aging such as muscle deterioration, respiratory inefficiency, and comorbidities like diabetes, obesity, and osteoporosis can further lengthen the road to recovery.
So, what can employers do to set up older employees for success – and safety – on the job?
CLOSE GAPS
The aging process makes certain tasks, such as those requiring exceptional flexibility and balance, harder for us to do. As a result, gaps between a job’s demands and a worker’s capabilities may form over time.
To close these gaps, employers should review the distribution of work at their company and consider how they might capitalize on the expertise and strengths of aging employees while keeping their physical, psychological, and physiological needs in mind. Here a few options to consider:
- Offer more frequent breaks throughout the workday.
- Minimize shift work and increase morning hours to allow older workers to punch the clock at optimal times
- Institute a job rotation system so an older worker is alternating tasks (rather than overexerting the same muscles throughout the day)
RETOOL YOUR EQUIPMENT
Although employees come and go, it is not uncommon for workstations to go unchanged for many years. It is important to periodically review workspace configurations to ensure they are not exacerbating workplace injury.
Physical therapists and occupational health consultants can work with employers to conduct an ergonomic assessment and make suggestions which might include:
- Raise work surface areas or countertops
- Reconfigure at-hand work materials to minimize repetitive squatting, kneeling or twisting
- Reposition overhead equipment to waist-to-chest level
- Replace thin handles with thicker handles for better control
- Redesign equipment for more efficient exit/entry to minimize contortion
EMPOWER YOUR EMPLOYEES
A comprehensive occupational training and education program is critical to workplace safety, but more and more companies are also prioritizing health and wellness off the clock. After all, a more physically fit worker has better success in recovering from an injury.
Here are just a few ways employers can encourage workers to take health and safety into their own hands:
- Initiate an on-site strength and conditioning program to minimize workplace injury
- Offer partial or full payment for a local health club membership, contingent upon a minimum number of visits
- Build a culture of wellness in the workplace by offering healthier food options and opportunities for light physical activity (e.g., walking meetings) throughout the day
These operational changes should not be viewed solely as interventions, but as investments with long-term returns. By looking out for the well-being of our aging workforce, we effectively create safer work environments and reduce costs while securing a tried-and-true source of wisdom, dedication, and leadership in our industries for years to come.
Dec 29, 2015 | Insights
Claims professionals have long known that some injured workers don’t recover, and not because their injuries are catastrophic or intrinsically unrecoverable.
By Ruth Estrich
In recent years, the managed care industry has focused on pain management solutions to address these delayed recovery cases.
However, recent studies show that while pain is an obstacle to returning to meaningful work and life roles, it is not as significant a deterrent as many assume. In fact, some symptom-based interventions, e.g., programs that only focus on pain, can actually increase disability duration rather than minimize it.
Increasingly, research is pointing to psychosocial barriers as a more important variable than pain, accounting for more than three times the variance in the magnitude of disability (Journal of Occupational Rehabilitation). Psychosocial factors, also commonly referred to as “yellow flags” arise from behavioral traits that reflect the relationship between the injured workers’ personal attributes and their social environments. Yellow flags can reflect personal, environmental and/or occupational work barriers and may be unrelated to the accident or presenting injury. Additionally, studies have identified the psychosocial barriers that have the greatest impact on delayed recovery and that can be mitigated by behavioral interventions:
- Catastrophic Thinking: The tendency to ruminate about irrational worst-case outcomes. Clearly, this can increase anxiety and prevent the injured worker from taking action, e.g., successfully completing their rehabilitation treatment program.
- Perceived Injustice: The injured worker’s belief that nothing will ever make up for what happened to them, and that they didn’t do anything to deserve their situation. Recent studies show that the combination of pain and perceived injustice increases depression significantly.
- Fear/Avoidance: The avoidance of movement and activity in an attempt to reduce pain. Studies show that this barrier generally results in both chronic pain and a disengagement from meaningful activities, which prolongs disability and also often leads to depression.
- Disability Beliefs: Injured workers’ expectations about recovery and their ability to manage returning to work. Studies in the Netherlands found that individuals’ perceptions of the impact of their condition had more influence on lost time, levels of impairment and activity levels than did actual physical or medical indicators.
Programs that identify injured workers who are at high risk for these critical psychosocial barriers and that deliver interventions that integrate behavioral and physical treatment approaches have been shown to be highly effective in 10 countries worldwide. Results from various studies led by Dr. Michael Sullivan, one of the foremost experts on psychosocial issues, cite a 77 percent enrollment success, a 33 percent reduction in the ongoing use of pain medications, and a 60 percent return-to-work outcome.
Of course, the earlier psychosocial issues are identified and addressed, the better. The American Physical Therapy Association has long noted that physical therapists are the providers who spend the most time with injured workers on the road to recovery, making them well positioned to observe – and if trained properly – mitigate these complicating factors. So it is not surprising that innovative new solutions are looking to physical therapists to provide psychosocial as well as musculoskeletal rehabilitation.
MedRisk’s Chief Strategy Officer Ruth Estrich has more than 30 years’ experience in managed care, both in workers’ compensation and group health. Estrich can be reached at restrich@medrisknet.com.
