Tip Old-fashioned doctor

[Diane]

Minn. doctor accepts cash, but not insurance.
1. Is this the answer?
2. Does it contain sufficient American political values?
3. What happens if the patient requires hospitalization, for say a broken leg, or a real heart attacK?
4. Or would Americans prefer medical handholding at the bedside until they croak?
5. Should hospitalization be in a different category of "medical" care than mere Dr. visits?

Just asking.

[keithp]

I hope so...our country's financial healthcare reimbursement problems are (in my estimation) a cultural issue, not a healthcare issue. I consistently felt that the "healthcare reform" was mis-characterized thoughout the last few years as the focus was directed at "preventative" medicine and cutting back on fraud.

I think that moving to insured catastrophic coverage and cash pay the rest of the way would:
1) Benefit the best practitioners...no longer would BCBS reimburse the worst practitioner in town the same as the best. Medicine would become incentivized to produce results, not visits and procedures. Charge what you like, if you are good enough, you will get it. Provide Pro-Bono or charitable care at your own discretion if you can afford it.
2) It would take a generation or two, but I believe that the individual would be forced to take on a greater accountability for their own health. We as a culture rely far too much on technology (medicine, prescriptions, etc) to allow us to continue to live unhealthy lifestyles because the cost is offset by insurance. If we went to a cash pay system, it would become cheaper and more efficient to simply take care of the body one has by utilizing some common sense rather than walking around town wearing a T-shirt that I saw being worn by a morbidly obese woman the other day that read, "Eat Right. Stay In Shape. Die Anyway."

If the US doesn't start to change the reimbursement model, I fear...well...it just doesn't look good, does it?

Originally Posted by Diane

Does it contain sufficient American political values?

Forgive me, but I am unsure what you mean by this.

Professionally,
Keith

[Jason Silvernail]

[Pulls up chair, starts eating popcorn]

[John W]

[No butter on mine, please.]

[Diane]

Hi Keith,
As soon as the popcorn eaters swallow, I'm sure they'll fill you in on all this.

[keithp]

Originally Posted by Diane

Hi Keith,
As soon as the popcorn eaters swallow, I'm sure they'll fill you in on all this.

Ruh Roh...seems me should have used the search function before responding, huh? ::

Not that discussion isn't fun, but if I have just poked upon something that has been discussed ad nauseum, a simple link will do for my review...not trying to avoid debate/conversation, but time is valuable after all. Then again, there is no enjoyment in eating popcorn in front of a blank screen...unless you just REALLY like popcorn.

(sits down in the front of the room, anticipating his first course in SS dissonance)

Professionally,
Keith

[Diane]

I thought this would be an interesting topic! Guess not..

So, there are at least two themes here, each with international implication:
Theme 1:
The Patient's Brain. The article describes something rather idyllic -
1. doctors willing to be paid retainers, or in goods rather than money, reducing the inflated costs of (simple) medical attention. Elicitation of all that powerful placebo.
2. doctors willing to come to the patient's context and visit him or her there. Letting the patient retain his/her physical, psychosocial comfort zone.

Discussion of the international angle on this point, would fill in around:
1. countries capable of transferring the illusion and/or reality of placebo elicitation over onto a single payer in countries whose value system seems rather stable regardless of who is in 'government' at any given time,
2. versus those that definitely cannot seem to, because of the continuously whipped-up and exacerbated clash of diametrically opposed values, or
3. those that just can't afford it and rely on foreign aid/IMF machinations.

Theme 2:
The second one is the issue of physician-owned PT clinics, and its implications. Surely PTs would be pleased to see their "owners" disappear so they could get on with owning control of their own fates. If all the authentic (patient-centered) doctors quit insurance and went off to be paid in pies and dead chickens; then it would be easy to see (and avoid maybe) who was in it only for the $.

I should think that PTs in each of the kinds of countries listed above would have different experiences based on what their medical systems are like, based in turn upon what that country's political systems are like.

The older I get the more I can see the impact of different systems on their citizens, downstream through time, from the POV of being a PT, PT being a relative latecomer profession to whatever national system we're talking about.

Zooming in, it seems to me that in Canada our national PT body must have fallen down on the job, maybe in the 80's or 90's. I don't know exactly when, because I wasn't following PT business carefully enough at the time. I woke up like Rip Van Winkle a few years ago to see PT in Ontario overrun with chiro-owned PT practices. My insular cortex is still in a state over this: I've assured it that there would likely have been nothing that could have been done anyway and have reminded it about how inactive and disinterested it had been about stuff like this 3 decades ago. So, I don't know what happened exactly... other than, maybe the chiros saw MDs exploiting PT in the US and decided to position themselves as the "physicians" who would exploit it in Canada. Well, Ontario. Maybe Alberta. There is none of this happening in the two provinces that I know about (at least as far as I know), BC and Sask. As far as I know, MDs do not own/operate any PT clinics in Canada. Maybe someone can enlighten me if I'm wrong about that.

[Jason Silvernail]

Keith-
In contrast to perhaps some other places out there in internet-land, the moderators here don't do groupthink and we don't always agree on things. We've had many healthcare policy type discussions here and Diane and I will just never agree on some fundamental policy issues. The nature and extent of those discussions are well known (at least to me) and therefore I wasn't about to jump in with both feet on this one. Since neither of us is in any sort of policy-making role our opinions don't go beyond good discussion anyway.

The referral for profit issue is another thing entirely and happy to discuss that in detail as it affects our patients so much. I didn't really see that as a main issue with the lead off post so therefore was just pulling up a chair to watch the show rather than participate.

Previous discussion: Healthcare Reform

[keithp]

Originally Posted by Jason Silvernail

Keith-
In contrast to perhaps some other places out there in internet-land, the moderators here don't do groupthink and we don't always agree on things. We've had many healthcare policy type discussions here and Diane and I will just never agree on some fundamental policy issues. The nature and extent of those discussions are well known (at least to me) and therefore I wasn't about to jump in with both feet on this one. Since neither of us is in any sort of policy-making role our opinions don't go beyond good discussion anyway.

Previous discussion: Healthcare Reform

And with my history and experience lying in participation in message boards exclusively in the US, I approached my response with an admittedly geo-centric viewpoint that was lacking some of the depth and experience that was probably sought after in this particular context.

Thanks for the link...will be sure to check it out and come back to this thread after (to avoid being redundant). Just gotta find the time...

Professionally,
Keith

[TexasOrtho]

You should try some Tony's on yours. Beats butter and should be readily available in New Orleans.

[Jason Silvernail]

Keith-
Let me save you some time. People's worldview and politics color their opinions of how we should centrally plan the delivery of healthcare via the government. Other people's worldview and politics color their opinions as to whether we should centrally plan the delivery of healthcare via the government. Still another group's worldview and politics color their opinions as to how much central planning of healthcare we should allow the government to do.
These groups don't agree and there are not enough facts to make a strict empirical case without invoking worldview or politics or having cultural differences between countries and people impossibly blur the arguments. Shortly the argument devolves into values rather than policy because that's ultimately what we are talking about. Among mature adults those values are unlikely to change in a significant way. So I don't see much point in discussing it, I'd rather just eat popcorn.

On the referral for profit issue, much could be said, but maybe another thread should be started. As of this writing (June 2011) several bills for "direct access" for patients to physical therapists have been winding through the legislatures of various states here in the USA. There is much worth discussing here IMO.

[John W]

The only issue I see here related to physician ownership of PT is probably the single biggest factor in this particular physician's decision to reject the current health care delivery system. And that is the stringent imposition of protectionism by the medical profession going back to the early half of the 20th century.

My grandfather practiced medicine from the 20s through 40's. Therefore, most of his practice was during the Great Depression. Very few of his patients had insurance, and those who did had a catastrophic plan that was underwritten by the hospitals (the original Blue Cross plan). Virtually all of his patients paid cash- or even bartered- for services just like this doctor in Minnesota. This was a time when the American Medical Association (AMA) was just starting to gather steam and amazing advances in pharmacology and technology were being made. The AMA saw the potential financial benefits in harnessing these scientific advances and wanted to make sure that physicians were the sole decision-makers regarding which technologies would be utilized for which patients. They wanted control, and saw themselves and uniquely qualified to have that control.

They developed extremely stringent requirements for medical school, which created a constant low supply of physicians in the marketplace, which exists to this day. They developed strict licensure requirements, which restricted any other profession from so much as placing a hand on a patient without the express permission of a doctor. They even established their own insurance plan (Blue Shield) as they began to see how much money hospitals were starting to make in an ostensible effort to "compete" with the hospitals. This all occurred in a backdrop of huge social-engineering policies by the the Roosevelt Administration in the 30's and 40's. It then gained considerable steam in the 60's under LBJ, who, with an extremely liberal Congress, was able to pass Medicare.

Despite incredible advances in medical science and technology since the 60's, quality of care has flat-lined while costs have skyrocketed. There is nothing surprising about any of this if you ask any decently-trained economist (who doesn't currently work for the government and has a vested interest in maintaining the status quo). The problem is protectionism- a blatant attack on free trade practices, which have been proven time and time again to provide the highest quality and least expensive goods and services to society.

Physician ownership of PT is just one small example of these efforts by the medical profession to control any and all health care delivery. These protectionist practices by the medical profession explain the advent of "alternative" medical providers such as osteopaths and chiropractors, which the traditional medical profession fought against tooth-and-nail. However, due to popular support of less expensive/technocratic and often more effective care for nagging musculoskeletal conditions, these professions were able to grow and thrive, despite the many problems with the lack of rigorous science to support what they were doing.

So, we can blame the medical profession (and, of course, the politicians they bought and paid for) for being beset with half-baked chiropractic and osteopathic theories in musculoskeletal care.

[Jon Newman]

I agree with Jason. That thread is all old news but entertaining nonetheless. As you can see, all the hopeful predictions, as well as all the doomsday predictions, came to fruition. Especially that part about death panels.

Reading the thread made me feel rather like these pundits (whom I expect are about as accurate as the mainstream ones):

Psychics make global finance predictions

[keithp]

Originally Posted by Jason Silvernail

Keith-
Let me save you some time....

Thanks...I have bookmarked that thread for another day, but would prefer to learn something applicable to my going back to work tomorrow, not that I don't find theoretical political conversation fun and (soemtimes) enlightening

Originally Posted by Jason Silvernail

On the referral for profit issue, much could be said, but maybe another thread should be started. As of this writing (June 2011) several bills for "direct access" for patients to physical therapists have been winding through the legislatures of various states here in the USA. There is much worth discussing here IMO.

Direct Access is great, but has had little effect on anything in NY state...yet. In my region there is a orthopedic group that handles (I would guess) 60-70% of all ortho cases in total...they are huge. The paradigm continues with the patient seeing their PCP, where they get some meds. After 2 weeks, if they do not feel better, they go back and are advised to get an ortho consult or try PT. Luckily, a lot of people choose PT, but many will wait for 3-4 weeks to see the ortho "expert" and they are then funneled into the POP and when that doesn't work, the patient is lucky to enough to have the pain management office in the same building as the orthopod and PT.

Can we (as PTs in NY) provide direct access? Yes, but it is not reimbursed by Medicare as they won't pay without a Rx from MD. Many private insurances also require a MD script for authorization as well. Couple that with the lack of awareness of the public in general regarding physical therapy and our inability to establish value (heck, the generic chiro is usually better than us in that regard)...well, direct access becomes a first step in the right direction, but only a first step.

Fortunately, a group of PT-owned practices locally are planning on coordinating their efforts (to the best of my knowledge) in coordinating an awareness campaign, pooling their finances in a effort to market the profession of physical therapy itself...but it will be interesting to see how it plays out.

Originally Posted by John W

...Physician ownership of PT is just one small example of these efforts by the medical profession to control any and all health care delivery. These protectionist practices by the medical profession explain the advent of "alternative" medical providers such as osteopaths and chiropractors, which the traditional medical profession fought against tooth-and-nail. However, due to popular support of less expensive/technocratic and often more effective care for nagging musculoskeletal conditions, these professions were able to grow and thrive, despite the many problems with the lack of rigorous science to support what they were doing...

Good posting (the whole thing, not just what was quoted above). The bolded was what I was referencing earlier in regards to the US citizen living within a culture that is not conducive to "good health", despite the "advancements" made over the last 40+ years.

Tangential Thought: It is sadly ironic that I have been on my soapbox for years about the inability of the average US citizen to assimilate the most basic of health knowledge into their lifestyle, yet I am just now coming to hear of a neuromatrix and neurodynamics after being involved in PT (in one capacity or another) for >16 years.

[Jon Newman]

Originally Posted by keithp

Couple that with the lack of awareness of the public in general regarding physical therapy and our inability to establish value (heck, the generic chiro is usually better than us in that regard)...

Hi Keith,

Can you expand on this? I don't know what you mean by "our inability to establish value".

Thanks.

[keithp]

Originally Posted by Jon Newman

Hi Keith,

Can you expand on this? I don't know what you mean by "our inability to establish value".

Thanks.

Sure...I am under the impression that people don't know when seeing a physical therapist can be fruitful, what we are capable of addressing, or how we may address one's complaints (other than pelvic tilts, perhaps). How often have you asked a patient, "So, what brings you in today?", and they respond, " I don't know, my doc told me to come here." Or how often have you had someone who attends they initial visit with no idea what to expect or what physical therapy entails. I find that there is a greater percentage of people (anecdotal, sure) who have an understanding of what to expect from a MD, Chiro, Massage therapist, Psychiatrist, Nutrionist, Acupuncturist, etc...but we (as a field) have done a poor job of letting people know what we have to offer. We have done a poor job historically in letting people know what we do. Therein, someone is unable to value something (my service, knowledge, etc) and they, most definitely, are not likely to seek me out in a direct access environment.

Granted, maybe it is because there is such variability in what we do as a field. Maybe it is that we are not as successful as we would like to think we are. But regardless...despite my own inadequacies (which are brought to the fore-front to a greater extent on a daily basis, I assure you), I would still be hard-pressed to believe that my results are worse for LBP pts than the chiro, surgeon or acupuncturist in town...but people will often try one of those "remedies" before walking into a PT clinic. I believe that until PT is brought to the front of the collective awareness of the community as a whole (the "go to" clinician for pain and movement dysfunction), direct access (even if legal) will not be fruitful.

The APTA has recognized this, thus the start-up of their Moving Forward campaign a couple of years ago...it just falls far short of something that is substantive enough for a wide spread success. Thus, some local clincians in my area are contemplating how to market the field as a whole in a way that is mutually beneficial to a variety of clinics, even if we may be considered competitors.

Professionally,
Keith

[Jon Newman]

While I've heard that sort of thing for sure, I've had a more varied experience. I've even had some people, whom I've never met, turn their head away from me upon my saying "Hi, I'm Jon from physical therapy", and I don't think it was my reputation preceding me.

I find the public I run into have expectations of being exercised, stretched, strengthened, aligned and may also expect hot/cold packs, US, or massage.

Physical therapists do see a wide variety of people across all age groups. What do you see as the common denominator? What expectations do you think the public should arrive to therapy with?

Should we start a new thread for this?

[nari]

Should we start a new thread for this?

Good idea, Jon. It might show up cultural differences between states, countries in terms of expectations.
I have to gather my thoughts together first and then join in.

Nari

[Diane]

Originally Posted by Jon Newman

Should we start a new thread for this?

Or we could just keep on going in this one.

(Reading that health reform thread from a couple years ago was a blast. )

[Barrett Dorko]

Meeting someone for the first time and telling them who I am is the most important moment in the entire process of therapy.

I do all I can, and this has become an intricate dance driven by the patient. This CANNOT be driven by any single spiel or predictable manner of movement. I don't touch them until given permission, usually through a nonverbal assent.

I'm always asked by some students, "What exactly do you say?"

When they ask that, I always feel sorry for their patients.

[nari]

One opening gambit which I heard quite frequently from various PTs:
Hello, what can I do for you? Inevitable reply: Well, I have had this pain (here) and I probably need some massage or something...

To me, that is NOT the way to meet a patient initially. I've always had a bad habit of not introducing myself first, and never really got over that fault; but in order to establish a rapport, I'd invite them to sit down and say something like: How's things? Probably an Aussie adage, but it always worked - the pt opened up with the problems quite quickly, including their expectations.
Interestingly, if they had seen a doc who had suggested some modality or exercise, they asked if that was appropriate. (Usually it wasn't.) When I said there were other approaches which might be better, they often grinned and said: You're the expert.

If they had been to a chiro or MT, almost always they would ask if they should stop going while they are here with me. I'd usually suggest it would be a good idea for a week or two so it could be determined which attendance was more beneficial. If they missed the chiro cracking their spine each fortnight, then it was up to them to decide whom to stay with.

Most of the public think of physiotherapy as manual therapy with lots of exercises and stretching, in order to alleviate pain. But that probably comes from the public system, where modalities have virtually ceased to exist. (Not so in the private system!!) The wider use of neurodynamics has also crept in over the last 6-7 years, resulting in the public's improved understanding of the nervous system and pain. Hopefully...

Nari

[keithp]

Originally Posted by nari

One opening gambit which I heard quite frequently from various PTs:
The pt opened up with the problems quite quickly, including their expectations.

I can see that this will be interesting in how differently my pts approach their evaluation...more often than not, I have to pull teeth just to get functional goals from them, let alone come into PT with an expectation.

Originally Posted by nari

Interestingly, if they had seen a doc who had suggested some modality or exercise, they asked if that was appropriate.

Just the other day I got, " Did you review the paperwork that the doctor sent over? It tells you what you can and can't do and what he wants...you read that right?". The Rx read: LBP, Eval and Treat.

Originally Posted by nari

When I said there were other approaches which might be better, they often grinned and said: You're the expert.

Dang...how much does a work visa cost in Australia?

Originally Posted by nari

Most of the public think of physiotherapy as manual therapy with lots of exercises and stretching, in order to alleviate pain. But that probably comes from the public system, where modalities have virtually ceased to exist. (Not so in the private system!!)

Pts routinely become aggitated b/c I often will not provide them with a hot pack/stim; their idea of PT often includes modalities ahead of all other things. If I go to do a HVTM, I am asked if I went to chiro school too. I am definitely perceived as an exercise and modality clinician, first and foremost; if someone comes in with a notion of what PT may be. Unfortunately, many (not all) pts attend PT with the expectation of being a passive participant while I "make" them better.

Don't mistake me, after conversation re: why I think a mod may be a waste of their time and money and of what they SHOULD expect from their episode of PT care, all is fine...but there is a larger educational component than I would like in regards to the patient's expectation of care.

Originally Posted by nari

The wider use of neurodynamics has also crept in over the last 6-7 years, resulting in the public's improved understanding of the nervous system and pain. Hopefully...

I am a PT who is just beginning to make efforts to understand this realm...and I fully expect to get some/many odd looks from my colleagues along the way. I can only imagine how much this is going to require a shift in thought by the average patient who walks in my door.

In the end, the examples above are more the rule than the exception in my experience...thus my remarks about the need to educate patients (at least in my corner of the US) as to the role of the PT in the management of their pain/movement dysfunction. It seems that you are in a more advantageous position in regards to your higher esteem in the public eye in your locale than I am in mine.

Professionally,
Keith

[TexasOrtho]

Originally Posted by Barrett Dorko

Meeting someone for the first time and telling them who I am is the most important moment in the entire process of therapy.

I do all I can, and this has become an intricate dance driven by the patient.

Completely agree. The first five minutes is huge. I once tried to have a semi-standard greeting, but that flamed out quickly when I first started to realize there are no "standard" patients. The initial evaluation is definitely like a dance. I'm getting better but still get the white-man's overbite at times.

On a somewhat related note, I try to break my students' of referring to patients as "The TKA". It now officially drives me nuts.

I also believe that the office staff need to be keenly aware of how communication effects patients. We are very fortunate to have the best office manager on the planet (been working with her 6 years now), so I never stress over this.

[John W]

I'm getting better but still get the white-man's overbite at times.

Two years in West Africa cured me of that- I discovered that moving to the rhythm of a beat was actually supposed to be fun and carefree and not just some show to supposedly impress the opposite sex (in my particular case).

I am a PT who is just beginning to make efforts to understand this realm...and I fully expect to get some/many odd looks from my colleagues along the way. I can only imagine how much this is going to require a shift in thought by the average patient who walks in my door.

You may be surprised about how much more quickly your patients adapt than your colleagues. Working with a patient's neuromatrix involves the use of metaphors that patients can relate to and often places them at considerable ease with respect to these new ideas. When you get a chance during all of your reading, Keith, be sure to take a look at Moseley's Painful Yarns. It's easy to read, very funny and appeals to an aspect of being a clinician that you can't get from research articles and textbooks (Barrett's essays are indispensable for this a well).

I'm in New Orleans now, and I recently used a metaphor of excessively spicy food to describe a hypervigilant pain response. It seemed to go over quite well. One of the mods here, Cory, came up with the term "contextual architect", which I think as you come to better understand the pain neuromatrix, you'll see how this is achieved. I can assure you of this, becoming a contextual architect is a lot more interesting and fulfilling than cracking backs and training someone how to contract their transversus abdominis.

[nari]

Keith,

You may be surprised about how much more quickly your patients adapt than your colleagues.

John is spot-on here. Patients are nowhere near as 'hard-wired' as PTs are; except for those who are addicted to pops and crackles and only come to PT under sufferance.

Another thing - I live in a relatively small city with the highest per capita salaries in the country. No doubt the clientele who comes to see a HP are better educated than the average and more open to alternative approaches.

Nari