Guest guest Posted December 30, 2011 Report Share Posted December 30, 2011 [image: Posterous Spaces] [image: Your daily Update] December 30th, 2011 Science-Based Medicine » Strains, sprains and pains<http://ptmanagerblog.com/science-based-medicine-strains-sprains-and-pa> Posted about 24 hours ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=91060064> Strains, sprains and pains<http://www.sciencebasedmedicine.org/index.php/strains-sprains-and-pains/> Published by Jann Bellamy<http://www.sciencebasedmedicine.org/index.php/author/versus/>under Acupuncture<http://www.sciencebasedmedicine.org/index.php/category/acupuncture/> ,Chiropractic<http://www.sciencebasedmedicine.org/index.php/category/chiropracti\ c/> ,Legal <http://www.sciencebasedmedicine.org/index.php/category/legal/>,Politics and Regulation<http://www.sciencebasedmedicine.org/index.php/category/politics-and-r\ egulation/> Comments: 2<http://www.sciencebasedmedicine.org/index.php/strains-sprains-and-pains#commen\ ts> What do you think would happen if you gave a bunch of “complementary and alternative medicine” practitioners access to a big pot of money — say, up to $10,000 per patient — and let them treat patients virtually without restriction, hampered only by a fee schedule. No utilization review, no refusal based on a treatment’s being “experimental” — none of the usual foils which trip up CAM practitioners in the health insurance field. Think they’d run up the bill? Yes, they would. In fact, that’s exactly the scenario playing out in Florida right now with the state’s no-fault auto insurance. Good intentions, and the road from there Some background: The Florida legislature mandated no-fault motor vehicle insurance coverage personal injury protection (or “PIP” coverage, as it is commonly called) for all vehicles in 1971. The laudable goal was to give those injured in auto accidents ready access to money for economic losses, such as medical bills and lost wages, without having to determine who was at fault, a process litigation could delay for several years. Up to $10,000 in coverage is currently required for all vehicles. For medical bills, this coverage is meant mainly for temporary, and therefore generally minor, injuries. Bodily injury coverage – and the necessity for proving fault – takes over for more permanent injuries. Indeed, for 2007, according to a recent report by the Insurance Research Council<http://www.insurance-research.org/research-publications/pip-claiming-beh\ avior-and-claim-outcomes-florida%E2%80%99s-no-fault-insurance-system>(IRC), 70% of injuries reported by no-fault auto insurance claimants were sprains and strains. By statute, only medical doctors, osteopaths, dentists and chiropractors can supervise, order or prescribe medical services for PIP claims. However, physical therapy, massage and acupuncture can be prescribed by the provider. Medical costs represent 90% of all claimed economic losses, according to an analysis of 2007 Florida PIP claims, even though coverage is meant for other expenses due to injury as well, such as lost wages. In fact, medical expenses eat up so much of the $10,000 limit that there is often little – or no – money left for lost wages. Since 1971, vehicle and highway safety have improved dramatically, reducing the severity of crashes and resulting injuries. According to the Florida Highway Patrol, between 2006 and 2010 alone there were 21,000 fewer traffic accidents and only a 1.5 percent increase in the number of drivers. So, over time, there’s a trend toward fewer, less serious, accidents. As well, the injuries covered by PIP are mainly minor and self-limiting. But in Florida PIP coverage rates are out of control. According to a report issued by Florida’s Chief Financial Officer (CFO) Jeff Atwater the state’s paid PIP losses per auto have increased over 66 % in the last 2.5 years, and PIP premiums will double every 3 years if the trend continues. Faced with these stats, the CFO (whose office regulates insurance) decided to look into things and gave the Office of Insurance Consumer Advocate the task of doing so. The Consumer Advocate’s report<http://www.myfloridacfo.com/ica/docs/PIP%20Working%20Group%20Report%2012.\ 14.2011.pdf>, issued this month, produced some very interesting data on the question I posed in the first paragraph. And the results are . . . The Consumer Advocate found that, for 2010, the most expensive average provider charge per PIP claim was paid to these top three providers: - Massage Therapist: $4,350 - Acupuncture: $3,674 - Chiropractor: $3,482 In contrast, the three provider types with the lowest charge per claimant were: - Emergency Medicine: $1,613 - General Practice: $1,826 - Orthopedic Surgery: $2,810 Yes, you read that right. Over 4,000 bucks for massage therapy but only about $1,600 for the ER doc. Remember that a full 70% of these claims were – if the 2007 stats held true for 2010 — for strains and sprains. And let me go out on a limb here and guess that the emergency medicine doctors and orthopedic surgeons were treating the more serious types of injuries. Yet, they still came out far below the average per claim charges for massage therapists, acupuncturists and chiropractors. And there are other interesting stats in the report. Forty-three percent of Florida PIP claimants saw a chiropractor in 2007, compared to 25% seeing a General Practitioner and 9% seeing a Physical Therapist. According to an IRC report referenced by the Consumer Advocate: Chiropractors are the largest percentage of medical providers submitting charges for treating PIP claimants and had the highest average total charge per claimant as compared with other medical providers. Although, as we can see from the data for 2010, even they have been surpassed in average charge per claimant by massage therapists and acupuncturists. As well, the IRC report noted: Treatment by a GP tends to involve many fewer visits than treatment by other types of providers. For PIP claims countrywide closed in 2007, claimants treated by GPs had 4.8 GP visits, on average. In contrast, PIP claimants treated by a chiropractor had 21.7 chiropractor visits, on average. That’s right, rounded off, 5 visits versus 22 visits, over four times as many. Think of the poor patient: maybe 22 times getting off work or getting a baby sitter. The carbon footprint alone for 22 visits is alarming. And all this for a strain or sprain? But is it worth it? All of this raises an obvious question: Even if treatments by massage therapists, acupuncturists and chiropractors are more expensive, are they worth it? First, let’s examine that $4,000+ worth of massage therapy. Under state law, “massage” means<http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute & Sea\ rch_String= & URL=0400-0499/0480/Sections/0480.033.html> the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation. (I know, I know, colonic irrigation.) While the use of “any electrical or mechanical device” might seem scarily broad and open to abuse in pumping up the bill, it appears that the massage therapists billing for treatment of PIP claimants were actually performing, well, massage. In 2010, massage and deep tissue massage were among the top ten billed procedures in PIP claims. Measured in 15 minute increments, called “units,” there were a whopping 1,836,308 units of deep tissue massage billed, and an even more whopping 4,051,016 units of what is generically referred to as “massage” billed. That’s almost 6 million units total, which equals one 15 minute massage for about every third person in the whole state of Florida. (1) I’m no biostatistician, but I did look on PubMed to see what the evidence might be for massage. One Cochrane Review <http://www.ncbi.nlm.nih.gov./pubmed/18843627>found that “massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education.” In the cited studies, massage (of several different types), lasted between 10 minutes and one hour, for between one and 10 sessions. However, a 2007 Cochrane Review found <http://www.ncbi.nlm.nih.gov./pubmed?term=%22Cochrane%20database%20of%20systemat\ ic%20reviews%20(Online)%22%5BJournal%5D%20AND%20Haraldsson%5BAuthor%20-%20First%\ 5D>“No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.” I couldn’t find any good evidence on cost-effectiveness compared with other treatments. Thus, my lightly evidence-based conclusion is that, while massage might be beneficial for some types of low back pain (if this is the problem presented by the sprain or strain at hand), at $4,350 a pop it doesn’t appear that you’re getting your money’s worth. Massage is often included as CAM by CAM proponents<http://nccam.nih.gov/health/whatiscam/#definingcam>. I am not so sure that is a correct characterization. But for the purposes of this post, I’ll cede the point because it illustrates something proponents don’t particularly like to acknowledge: that what they call “CAM” can have some very real adverse effects on the public, even if they are not of the physical sort, a point I’ll return to later. Let’s move on to the far more studied acupuncture and chiropractic, which won second and third place, respectively, in the category we’ll call “Most Expensive Provider of Treatment for Mostly Inconsequential Injuries.” Sorting out the details on acupuncture is complicated by the broad scope of practice given acupuncturists under Florida law<http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute & Statu\ teYear=2011 & URL=0400-0499/0457/0457.html> : Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies, as defined by board rule. “As defined by board rule” is a boon to acupuncturists, because the acupuncture board has helped itself <https://www.flrules.org/gateway/ChapterHome.asp?Chapter=64B1-3>to a whole bunch of nonsense, including cupping, “thermal methods,” magnets, reflexology, laser biostimulation (whatever that is), recommendation of supplements and homeopathic preparations (which acupuncturists can also sell to the patient) and herbology. Thus, we cannot know from the Consumer Advocate’s report how much of a billed procedure was acupuncture or “thermal methods” or cupping. But from the fact that, as the law now stands, acupuncture would have to be prescribed by a covered provider (M.D., osteopath, chiropractor or dentist) or performed by the covered provider himself, I think we can safely assume that most of what was done was acupuncture, although we don’t know what kind. Acupuncture of all stripes has been the subject of numerous posts here at SBM <http://www.sciencebasedmedicine.org/reference/?p=34>, and we know that it doesn’t work <http://www.sciencebasedmedicine.org/index.php/spin-city-placebos-and-asthma/#mo\ re-14434>for anything<http://www.sciencebasedmedicine.org/index.php/pragmatic-studies-and-cin\ derella-medicine/#more-12523> .. Period.<http://www.sciencebasedmedicine.org/index.php/acupuncture-revisited/> This was recently confirmed by yet another study<http://www.ncbi.nlm.nih.gov./pubmed/21402332>. Thus the $3,674 per claim paid to acupuncturists is a huge waste of money. The problem will get worse if a bill proposed for the 2012 legislative session becomes law. It would amend the no-fault auto insurance statute to include licensed acupuncturists as covered providers. This would mean that the acupuncturist is in total control of the diagnosis and treatment, no referral required. Magnets, anyone? And finally, bringing up the rear of the top three, is chiropractic. In Florida, we adhere to the traditional, D. D. Palmer definition of chiropractic<http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Stat\ ute & Search_String= & URL=0400-0499/0460/Sections/0460.403.html> : the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education. As we know, the vertebral subluxation doesn’t exist<http://www.sciencebasedmedicine.org/index.php/the-image-of-chiropractic-co\ nsensus-based-on-belief/>. But tell that to the Florida Legislature. Given the ubiquity of chiropractic belief in the subluxation<http://www.sciencebasedmedicine.org/index.php/spinal-fusion-chiropra\ ctic-and-subluxation/>, and the fact that, according to chiropractors, these putative subluxations can be caused by accidents<http://www.chiropracticandmoore.com/doctor/chiropractor/22S/chiropract\ ic-Kissimmee/subluxation.htm>, it seems reasonable to conclude that at least some of the $3,482 per PIP claim charged by chiropractors is going to the detection and correction of the non-existent subluxation (or one of its many iterations, such as manipulable lesion or joint dysfunction) which is, after all, the very definition of chiropractic practice in Florida. But even when chiropractors branch out and include other treatments, the results are unimpressive. A recent Cochrane Review <http://www.ncbi.nlm.nih.gov./pubmed/20393942>looked at, for low back pain, “a combination of therapies such as SMT or adjustment, massage, thermotherapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification, and patient education” rendered by chiropractors. (2) The conclusion: Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. It is interesting to note that several of the therapies employed by chiropractors and included in the Cochrane Review are among the top ten PIP procedures billed for 2010. In addition to “Chiropractic Manipulation, 3-4 regions,” which came in number 10, at 1,023,671 procedures, we have the following, along with the number of these procedures performed last year on PIP claimants by all providers: - Electrical Stimulation (15 min.): 1,172,400 - Electrical Stimulation (time not specified): 2,219,955 - Hot Pack/Cold Pack: 2,315,997 - Ultrasound Modality (15 min.): 2,324,928 What’s the harm? The harm caused by CAM providers and their therapies is generally reported in terms of side effects of those therapies <http://whatstheharm.net/>. Here, we have evidence of a larger economic harm to the general public. Three CAM providers – as defined by CAM proponents – are the most expensive providers of PIP-insured claims. Of these, the main therapy of two – acupuncture and chiropractic – are scientifically implausible and have (as one might guess) no evidence of effectiveness. The third, massage, is the most expensive, with limited evidence of effectiveness and no evidence that it is more cost effective than other treatments. And all this for mostly sprains and strains. Obviously, there are other drivers of these huge premium increases in the PIP system. One is out and out fraud. Another is increased litigation, and here it is fair to note that claimants under chiropractic care were more likely to have an attorney. For 2007, the association between the type of provider and having an attorney were: - Chiropractor: 62% - Orthopedist: 24% - Physical Therapist: 15% And here’s the harm. According to the Consumer Advocate’s report, some Florida families are paying $3,500 annually in PIP premiums for $10,000 in PIP coverage. That’s right: more than a third of the total coverage amount in premiums. Another example from the report: A retired couple in Tampa with one car insured by State Farm paid $471 in PIP premiums this year. The average family with teen drivers and two cars in Tampa paid almost $2,000 to State Farm for the same coverage. If this family earned the $40,000 median income for Hillsborough County (Tampa), they would be paying an astounding five percent of that income for $10,000 in PIP coverage. We don’t know from the Consumer Advocate’s report how much of this can be attributed to diagnosis and treatment of conditions that don’t exist by covered providers. Nor can we know how much can be attributed to expensive treatment by massage therapists where less expensive but equally effective treatment might take its place.But we do know this. When given the opportunity to treat mostly minor, self-limiting injuries with methods of dubious, or no, effectiveness, and given expansive insurance coverage, CAM providers come out on top in terms of expense. And I’ll bet that’s a statistic you’ll never see CAM proponents quote. Notes 1. According to the 2000 census<http://myflorida.custhelp.com/app/answers/detail/a_id/933/kw/population/s\ ession/L3RpbWUvMTMyNTEwMDE3MC9zaWQvdFF5ekpLTWs%3D>, the population of Florida is 15,982,378. 2. To the uninitiated, the referenced “adjustment” means, in chiropractic lingo, adjustment of the aforementioned vertebral subluxation which, as noted, can’t do the patient any good because these subluxations don’t exist. via sciencebasedmedicine.org<http://www.sciencebasedmedicine.org/index.php/strains-s\ prains-and-pains/> Deloitte Review | I’m OK, You’re OK ... But Will We be All Right? | With the U.S. health care system undergoing massive change,<http://ptmanagerblog.com/deloitte-review-im-ok-youre-ok-but-will-we-be> Posted about 21 hours ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=91073426> I’m OK, You’re OK ... But Will We be All Right? With the U.S. health care system undergoing massive change, some stakeholders are taking bold, innovative steps [image: Deloitte Review - Did You Say Free?]By Bigalke, Copeland, Jr. and Keckley > Illustration by Yuko Shimizu In *I’m OK—You’re OK,* the 1970s self-help best seller, , M.D. describes a dynamic often seen when major changes take place within micro systems, such as individual relationships, and macro systems, such as entire industries. One “incumbent” or participant in the system will complain to another that, “you’re okay, and I’m not okay.” In other words, I’m getting a raw deal, and you’re not. Sound familiar? The U.S. health care industry is in such a state today. Since enactment of the Patient Protection and Affordable Care Act (PPACA), many stakeholders in the industry (as we’ve known it) have complained that new rules unfairly penalize them and don’t deal with the true nature of the needed reform. Regardless of the legislation, many existing health care-related organizations could face challenges in the long term unless they change their business models. The PPACA is merely the tipping point for an industry already under pressure from a variety of economic, demographic and competitive “stressors.” Evidence of a crescendo in industry upheaval is widespread. Industry consolidation via mergers and acquisitions is returning to a landscape that existed prior to the financial crisis.1 The Centers for Medicare and Medicaid Systems and state budget officers anticipate cuts to Medicare and Medicaid provider reimbursement, with ripple effects for all stakeholders.2New medical loss rules already in effect will limit health plan profits. 3 And virtually all health care-related companies will be subject to new excise taxes.4 For many businesses in the industry—as well as employers that fund health coverage and consumers who pay an increasing share of the tab—health care costs are causing an increasing burden. As some lawmakers and industry stakeholders remain focused on defining the appropriate role of government, and others debate specific components of health reform legislation, there are signs that the industry and American businesses are adapting to the new order. A few early innovators are actively responding to the financial, legislative and regulatory pressures in ways that really could make them okay: - *Innovative incumbents* are forming new alliances and identifying new niches. - *Nontraditional participants* are creating new business models and new products and services, thereby gaining access to health care markets that previously were off limits. A common trait of these fast movers is acceptance of the industry’s shift from a *volume* focus to a *value* focus. A closer look at why and how these leaders are tackling the dramatic change underway may be instructive for those in the health care business today, new entrants and other stakeholders because one thing is certain: inaction is possibly the fastest path to not being okay in the future. Why transformational change is happening: four stressors Four “stressors” – *government health care reform initiatives, economic constraints, clinical innovation and demographic changes* – have applied increasing pressure to the entire U.S. health care system for years, compelling many health care industry participants to change what are often longstanding practices. *Health reform *Passage of the PPACA in 2010 isn’t just the most recent of these stressors. The legislation represents the most fundamental shift in U.S. health care delivery since the creation of Medicaid and Medicare. In fact, components of the PPACA and other recent health reform initiatives are aimed directly at driving the transition from a volume-based to a value-based health care system. Some provisions of the PPACA will likely be, or already have been, subjected to repeal efforts in the U.S. Congress. Regardless of such initiatives, many elements of the act may provide momentum for irreversible change. [image: Some key components of health reform legislation] *Economic realities* The math is inescapably, brutally clear. Health care costs have grown on average 2.4 percentage points faster than the GDP since 1970.5 With no end in sight, this gap is simply not sustainable and is exacerbated today by the continuing challenges to the broader U.S. economy. In fact, only one in four consumers remain confident about managing future health care costs, according to Deloitte Center for Health Solutions research.6 One way employers are addressing growing health care costs is to shift from providing defined benefit coverage to offering defined contribution plans. This is much like the changes in the 1980s, when retirement programs switched from pensions to 401(k)s, which limited an employer’s liability and shifted more responsibility to employees. However, these moves do nothing to address two of the primary sources of cost growth: how much consumers are, or are not, assuming responsibility for their own health and well being; and the incentives associated with consumers changing their own behavior. Seventy-five percent of U.S. health care costs are associated with lifestyle and chronic disease.7 The dramatic rise in the nation’s obesity rate in the past 20 years offers a striking example of the problem. In 33 states, at least one in four residents are obese.8 Unless individuals alter their eating habits, exercise more and take medications as indicated, such numbers are only likely to rise. For their part, physicians are rewarded financially in today’s fee-for-service reimbursement system to admit more patients and use more tests, products and procedures. The inclination to emphasize volume over value can be intensified when providers hold financial interests in the facilities being used. Of course, a major area of concern amid the federal and state budget crises is the existing defined benefit entitlement programs, specifically Medicare and Medicaid. These programs are outsized contributors to the fiscal challenges facing federal and state governments. To the extent Medicare and Medicaid require cross-subsidization and higher taxes, as well as how they affect the cost of American-made goods, they will continue to affect the overall economy. The role, structure and viability of these massive programs will likely be the subject of intense congressional and public debate in the months ahead. *Clinical innovation *Treatment breakthroughs over the past decade are revolutionizing how and where health care is delivered and the effectiveness of the care. Many surgical procedures are now performed in a fraction of the time they used to take. Approximately 70 percent of surgeries are performed on an outpatient basis, according to recent estimates.9 Many of these innovations have been driven by the industry’s ability to amass and analyze clinical data through *biomedical informatics* – the field of science in which biology, computer science and information technology merge to form a single discipline.10 Researchers and clinicians are using this data to identify new patterns of care and to predict future events. In doing so, they are compelling the health care profession to shift from opinion-based medicine to evidence-based medicine. The intended result is a more substantial foundation for research into causes and improvement of care patterns. The promise of personalized medicine customized to a person’s unique genetic footprint is also becoming a reality. Among exciting initiatives underway is the Coriell Personalized Medicine Collaborative, a study designed to determine the utility of personal genome information in health management and clinical decision-making. The study aims to enroll 100,000 participants and be a model for ethical, legal and responsible implementation of genome-informed personalized medicine.11 In March 2011, Vanderbilt-Ingram Cancer Center launched “My Cancer Genome,” the nation’s first personalized cancer decision support tool. The Web-based information tool is designed to quickly educate clinicians on the rapidly expanding list of genetic mutations that impact different cancers.12 Clinical innovation drives change in the U.S. system. Consumers demand the latest and best, and physicians and hospitals are required to comply with ever-changing “best practices.” The pressure on the U.S. system to offer the latest and best is a major source of its strength, but also a major catalyst for its high costs. *Demanding demography *The impact on the health care system of aging baby boomers is widely recognized and reported – and must not be underestimated. The Congressional Budget Office predicts that, absent changes in the system, spending for Medicare alone could more than double to 8 percent of gross domestic product by 2035.13 At the same time, the ratio of Americans under age 65 to those over 65 will likely continue to drop dramatically, which could potentially accelerate the decline in the country’s ability to pay out defined-level Medicare and Social Security benefits.14 Aging isn’t the only demographic force pressuring the health care system. Addressing the needs of an increasingly multicultural population likely requires a new mindset toward different medical approaches. The United States is rapidly becoming more heterogeneous – by 2050, more than half the U.S. workforce is estimated to be non-Caucasian.15 Beyond unique medical problems experienced by certain ethnic cohorts, the growing number of internationally born workforce members adds pressure to incorporate Asian and ayurvedic approaches with traditional Western allopathic medicine. For example, Muslim patients are not inclined to accept blood from a donor, preferring autologous, or their own, blood instead. An Asian patient might decline a prescription drug in favor of an herbal remedy. The use of yoga to treat postmenopausal pain is becoming more popular among urban women, and the concepts of integrative health are being taught in many schools of medicine alongside traditional Western medicine. [image: The U.S. health system is big, complex, fragemented and expensive] Our aging, more ethnically diverse population is requiring the health system to make changes in its diagnoses and treatments. Changing the system from a homogenous platform focused on Western medicine methods to a heterogeneous one represents a huge paradigm shift. How early adopters are taking the initiative The four stressors described above are contributing to major shifts in the current health care industry structure (see Figure 1). The transformations can be grouped into two categories: incumbents working in new ways and nontraditional entrants pursuing newly emerging opportunities. The activities of both groups are driving changes that are critical to real health care system transformation, including increases in: - Access to information about the safety, quality and outcomes for services provided by doctors, hospitals, and long-term care providers. - Emphasis on the role of consumers as key decision-makers in choosing hospitals physicians and insurance plans that accommodate their needs. - Awareness of the scientific support for recommended treatment options and the gap between evidence and practice. - Alignment of incentives between purchasers (i.e., employers, health insurance plans, government programs) and providers — the shift from volume to value. - Investment in information technologies and care management tools across the system to facilitate coordination of care and reduce redundancies and paperwork. - Sensitivity to the costs of health care by policymakers and taxpayers coupled with new models for insuring consumers and employers against its risks. - Public debate about the role of the state and federal government in managing the health system as health reform is implemented. How are these activities playing out? Health plans and front line health care providers are joining forces to challenge traditional treatment models, share information in new ways, and develop new leading practices to deliver greater value for consumers. Technology companies are using advancements in communications and information technology to break down barriers between care system segments. Retailers are adding health services and expanding over-the-counter remedies to accommodate demand. Employers, health care providers and health plans are experimenting with new ways to encourage healthier lifestyles and more efficient use of the health care system among consumers. In short, old industry rules are being thrown out and new, at times unusual, relationships are forming among both incumbent stakeholders and nontraditional entrants into the market. Innovative incumbents are breaking down walls, forming new alliances Many forward-looking industry participants recognize they can no longer operate in silos. To survive, different segments may need to consider setting aside longstanding distrust and tensions and collaborate in new, novel ways – and move quickly. Leading incumbents, including doctors, hospitals, life sciences companies and health plans, are establishing a variety of arrangements across traditional boundaries. One example of this shift is the increasing employment of doctors by hospitals and health care systems. According to the New England Journal of Medicine, more than 50 percent of practicing U.S. physicians now work for hospitals or integrated delivery systems.16 Virtually every hospital is seeking ways to better align with doctors to reduce costs, address risks and provide better care from preventive measures through diagnosis and treatment. In the PPACA, doctors and hospitals are encouraged to share financial risk to qualify for payments or avoid penalties via accountable care organizations (ACOs), episode-based payments and other models.17 ACOs bring doctors, hospitals and other providers together to provide coordinated care to Medicare enrollees, with incentives tied to quality metrics and Medicare savings. The emergence of ACOs, along with other delivery models, is also providing opportunities for health plans. For example, in March 2011, Aetna and Carilion Clinic in southwest Virginia announced plans to collaborate in an ACO initiative. The relationship is ultimately expected to encompass co-branded commercial health plans for businesses and individuals, joint opportunities to provide personalized care, and new payment models that encourage providers to share accountability to improve patients’ health.18 Elements of ACOs and other delivery models could be linked by a medical “e-highway” that promotes sharing, better coordination, work flows, alerts and personalized applications that allow each user to get the most out of the data. Evidence of this may be seen in the development or acquisition by health plans of software companies providing this type of utility. OptumInsight—a business unit of UnitedHealth Group formerly known as Ingenix—focuses on providing the health care industry with information and analytics and establishing secure networks for information exchange.19,20OptumInsight is one player in what is evolving into a new “infomediary sector” within health care – businesses that amass and analyze clinical and administrative data and monetize and sell it to hospitals, doctors and pharmaceutical companies. Many life sciences companies are also realigning to strengthen their positions in the shifting health care landscape. Many large pharmaceutical companies are continuing to expand beyond their small-molecule focus into the large-molecule world of biotechnology. Biotech products such as vaccines and inhalers offer growth opportunities to companies buffeted by patent expirations and generic competitors to their traditional small-molecule, typically pill-administered products. A notable example of this trend is the 2009 merger of Roche and Genentech. The companies, which had partnered for nearly two decades prior to the deal, saw their merger as a way to simplify the structure of the combined organization and maximize the benefits of enhanced scale.21 The merger of Switzerland-based Roche and U.S.-based Genentech is an example of how life sciences companies are seeking to expand globally through relationships and collaborations. Another example of greater global focus is Pfizer’s 2010 acquisition from Biocon of Bangalore, India, of rights to four insulin products – one of a number of recent moves by Pfizer to expand its business in emerging markets.22 Nontraditional entrants are supporting and driving transformation Several realities are driving the growing interest in health care from outside the field. Nonincumbents are looking at the market in fresh ways, developing new approaches that provide the opportunity to create value both collaboratively with incumbents and to fill gaps in the existing system. Nonincumbents may also find the health care system’s “value gap” inviting. Deloitte* research found that 76 percent of respondents give the system a “C” grade or lower, and nearly half of them believe at least half of health care dollars are wasted.23 Many new entrants have access to capital. Demand for health services is soaring. The potential for both domestic and global growth, the size of the market and system inefficiency represent opportunities for investors. Among outsiders making a major impact on the industry are telecommunications and technology companies that are making deep pushes into health care. They are pursuing opportunities to help providers, health plans and Medicare and Medicaid share data more effectively and use broadband applications to conduct distance medicine. These companies are also supporting the engagement of consumers in “technology-enabled self-care” – using technology to provide medication reminders, make medical records available and educate consumers regarding their own health conditions and needs. Service portfolios, such as AT & T ForHealth, are accelerating delivery of wireless, networked and cloud-based solutions tailored to the health care industry.24 Such solutions include medicine bottles that remind patients to take pills on schedule, devices that monitor patients’ heart levels from their homes, and audio/video links that can replace the need for an in-person visit to the doctor. Thomson Reuters offers hospitals and health care providers evidence-based reference information for drug, disease, toxicology, patient education and neonatology through its Micromedex solutions.25 Micromedex markets products for medication safety, health and disease management, patient education and toxicology to hospitals worldwide. Other opportunity-minded outsiders are innovating in the delivery of information to support highly targeted therapies, with the goal of improving treatment and reducing spending on approaches that don’t produce desired outcomes. Companies such as 23andMe, Inc. and Navigenics offer consumers a tool to understand their own genetic information.26, 27 DNA analysis of saliva samples is used to identify disease risk factors, predict drug responses and uncover ancestral origins. 23andMe offers the service directly to consumers, while Navigenics offers it through sign-up with a physician or corporate wellness program. The status quo really is unsustainable As they work to make the U.S. health care system more “okay,” incumbents and nontraditional stakeholders are making important contributions to the system’s transformation. They are driving the critical shift from volume to consumer-oriented value, information-driven health care and coordination of care across an otherwise fragmented system. Increased access for those lacking insurance; improved care through better alignment of practices with evidence; and lower costs for consumers, employers and government purchasers are some of health reform’s goals. Getting there is, and will likely continue to be, messy as incumbents are pitted against each other and nonincumbents challenge traditional stakeholders with new business models and new and potentially better value propositions. Even as the rancorous political struggle over health care legislation continues, and as incumbents and nonincumbents clash, positive developments are happening across the system. The tension associated with transformation of the U.S. health system will likely result in its strengthening. Will all stakeholders end up “okay” going forward? Probably not. The question is who will prosper and who will fall by the wayside? Based on the advances described above, it seems likely that individuals and organizations that are open to new ideas; willing to revisit their value proposition to improve what they do from a competency perspective and change what doesn’t currently work well; and able to challenge the status quo could fare better than those that cling to familiar but outdated practices. If enough people and businesses move in that direction, the outcome really could be okay for the health care system and all of us it serves. *DR* * Bigalke** is vice chairman and U.S. national industry leader, Health Sciences & Government, Deloitte LLP. Copeland, Jr., is national managing director, Life Sciences & Health Care Practice, Deloitte Consulting LLP. H. Keckley is a director with Deloitte Consulting LLP, and is the executive director of the Deloitte Center for Health Solutions, Deloitte LLP.* *Endnotes* *1. McGladrey Capital Markets, LLC, April 2011, http://www.mcgladreycm.com/Portals/0/Quarterly Industry Reviews/2011_Q1QIR_Health care.pdf.* http://www.cms.gov/ReportsTrustFunds/downloads/tr2011.pdf *3. http://www.hhs.gov/ociio/regulations/medical_loss_ratio.html* http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf *5. “Health Care Costs, A Primer,” Kaiser Family Foundation, 2009, http://www.kff.org/insurance/upload/7670_02.pdf* http://www.deloitte.com/assets/Dcom-UnitedStates/LocalAssets/Documents/US_CHS_20\ 10SurveyofHealthCareConsumers_050610.pdf *7. http://www.deloitte.com/view/en_US/us/Insights/Browse-by-Content-Type/Newsletter\ s/health-care-reform-memo/6df082d93944f210VgnVCM1000001a56f00aRCRD.htm?id=us_ema\ il_CHS_HCRM_041111 * http://www.cdc.gov/obesity/data/trends.html *9. “Arise Healthcare opens new outpatient surgery center in CP,” Hill Country News, March 2011, http://www.hillcountrynews.com/news/business/article_5cd2de70-44f1-11e0-b101-001\ cc4c002e0.html * http://www.ncbi.nlm.nih.gov/About/primer/bioinformatics.html *11. http://www.coriell.org/index.php/content/view/92/167/* http://www.activehealth.com/activehealth-careengine.php *13. http://www.cbo.gov/ftpdocs/102xx/doc10297/Chapter2.5.1.shtml<http://www.cbo.gov/\ ftpdocs/102xx/doc10297/Chapter2.5.1.shtml%3Cbr%20/%3E> * http://www.cbo.gov/ftpdocs/120xx/doc12039/SummaryforWeb.pdf *15. “Supporting the 2010 Census: Toolkit for Reaching Business Organizations,” U.S. Census, September 2009,www.deloitte.com/us/about<http://www.deloitte.com/view/en_US/us/About/index\ ..htm> * http://healthpolicyandreform.nejm.org/?p=14045 & query=TOC *17. Patient Protection and Affordable Care Act, Public Law 111–148, March 23, 2010, http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf* http://www.aetna.com/news/newsReleases/2011/0310_Aetna_and_Carilion.html *19. http://www.ingenix.com/about/businesses/* http://www.businesswire.com/news/home/20110411005701/en/UnitedHealth-Group-An...\ <http://www.businesswire.com/news/home/20110411005701/en/UnitedHealth-Group-Anno\ unces-“Optum”-Master-Brand-Health> *21. http://www.gene.com/gene/news/press-releases/display.do?method=detail & id=11967<h\ ttp://www.gene.com/gene/news/press-releases/display.do?method=detail & id=11967%3C\ br%20/%3E> * http://www.bloomberg.com/news/2010-10-18/biocon-sells-rights-to-insulin-to-pf...\ <http://www.bloomberg.com/news/2010-10-18/biocon-sells-rights-to-insulin-to-pfiz\ er-for-upfront-200-million-payment.html.%3C/p>> *23. 2010 Survey of Health Care Consumers, Key Findings, Strategic Implications, Deloitte, http://www.deloitte.com/assets/Dcom-UnitedStates/Local Assets/Documents/US_CHS_2010SurveyofHealthCareConsumers_050610.pdf<http://www.de\ loitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/US_CHS_2010Surveyof\ HealthCareConsumers_050610.pdf%3Cbr%20/%3E> * http://www.att.com/gen/press-room?pid=18711 & cdvn=news & newsarticleid=3...<http://\ www.att.com/gen/press-room?pid=18711 & cdvn=news & newsarticleid=31334 & mapcode=corpo\ rate> *25. http://thomsonreuters.com/products_services/healthcare/healthcare_products/clini\ cal_deci_support/micromedex_clinical_evidence_sols/ * https://www.23andme.com/ *27. http://www.navigenics.com* www.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. via deloitte.com<http://www.deloitte.com/view/en_US/us/Insights/Browse-by-Content-Ty\ pe/deloitte-review/569ce7439cc41310VgnVCM1000001a56f00aRCRD.htm#.TvxzQMPqk0s.twi\ tter> Physical Therapy Diagnosis: New Treatment Based Classification Chart with Hyperlinks<http://ptmanagerblog.com/physical-therapy-diagnosis-new-treatment-bas\ e> Posted about 21 hours ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=91073628> Wednesday, December 28, 2011 New Treatment Based Classification Chart with Hyperlinks These are the Treatment Based Classification rules I've been using the past couple of years. Please use this chart, including the hyperlinks. Let me know if you see any ommissions or if you recommend a rule I have not included. Rule Author Year Level of Rule Development Cancer Rule in Lower Back Pain Patients <http://www.ncbi.nlm.nih.gov/pubmed/11251746> Joines et al 2001 Cost Effectiveness study Lumbar Manipulation Rule<http://www.ncbi.nlm.nih.gov/pubmed/12486357> Flynn et al 2002 Broad Validation Lumbar Stabilization Rule<http://www.ncbi.nlm.nih.gov/pubmed/16181938> Hicks et al 2005 Derivation Lumbar Traction Rule<http://www.ncbi.nlm.nih.gov/pubmed/18091473> Fritz et al 2007 Expert Consensus Thoracic Manipulation Rule for Neck Pain<http://ptjournal.apta.org/content/87/1/9.abstract> Cleland et al 2007 Broad Validation by Cleland in 2010 demonstrated NO rule is needed - ALL neck pain patients without " red flags " get manipulation Thoracic Manipulation Rule for Neck Pain<http://www.ncbi.nlm.nih.gov/pubmed/19252260> Whitman et al 2007 Derivation Hip Manipulation Rule for Knee Pain<http://ptjournal.apta.org/content/87/9/1106.short> Currier et al 2007 Derivation Specific Directional Exercise for Lower Back Pain<http://ptjournal.apta.org/content/87/12/1608> Browder et al 2007 Expert Consensus Lumbopelvic Manipulation for Anterior Knee Pain<http://www.jospt.org/issues/articleID.1387,type.14/article_detail.asp> Iverson et al 2008 Derivation Cervical Traction Rule<http://www.ncbi.nlm.nih.gov/pubmed/19142674> Raney et al 2009 Derivation Thoracic Manipulation Rule for Shoulder Pain<http://ptjournal.apta.org/content/90/1/26> Mintken et al 2010 Derivation via physicaltherapydiagnosis.blogspot.com<http://physicaltherapydiagnosis.blogspot.c\ om/2011/12/new-treatment-based-classification.html> [image: App] On the go? *Download Posterous Spaces* for your phone <http://posterous.com/mobile> Sent by Posterous. Is this spam? Report it here<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>. Manage or unsubscribe email subscriptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscri\ ptions>. Other questions? We’d love to help. <http://help.posterous.com> Quote Link to comment Share on other sites More sharing options...
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