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Sep162022NOCOMMENTS
Insurance Reimbursement

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Reimbursement Policy and Provider Behavior

Does Insurance Reimbursement Impact a Provider’s Clinical Decision Making?  Short Answer: ABSOLUTELY!!!

By: David P. Brungo, BSPT, MBA, MS, AIB-VA, AIB-VRII; Expert Contributor: Summerville PT & Balance Rehab for Adults

If you read that Blog Headline and have no idea what it’s really asking, here it is in more simple terms:  Most providers, such as your PCP, Neurologist, Orthopedist, Physical Therapist, etc., accept assignment by insurance companies.  That means they are contractually obligated to accept ONLY what the insurance decides it will pay for the services provided in addition to the patient’s co-pay and/or deductible.  The decisions insurance Boards make about what they will and will not cover, as well as how much they’ll pay to providers for covered services, have a huge impact on a provider’s ability to generate revenues and stay in business competitively.  Some providers are “cash based,” which means they do NOT accept what the insurance pays and instead charge the patient directly for all services rendered, after which the patient must submit their claims to their insurance for whatever their insurance would have paid to the provider.  We’re going to talk about how a provider’s clinical decision making might be affected by the coverage and reimbursement policies of their patients’ insurance.  In other words, how likely is it that a clinician’s real time decisions about what kind of as well as how much care to provide are INFLUENCED BY insurance reimbursement policy?  A very common generalized example of this is: Knowing that their patient needs X, Y and Z but the patient’s insurance only provides limited — or perhaps — no coverage/reimbursement at all, for X, Y and Z, will a clinician decide to do something mostly as a function of reimbursement level as opposed to providing what that provider believes their patient ACTUALLY NEEDS and that will be the BEST OVERALL intervention for the patient as opposed to just being the most attractive reimbursement to the provider?  Thus, there may be an ethical/professional dilemma to providers that is based entirely on insurance reimbursement policies.  The research on this is pretty clear and you may not like what it suggests.

“ETHICS” relating to health care and medicine are culturally defined and shaped by ideological philosophies and values.₁

As a physical therapist, I am required to be guided by professional ethics and standards of conduct just like every other health care provider.  Again, these are ideological in nature and may not align very well with reality, including a provider’s need to pay their bills, be “fairly” reimbursed for important and often highly complex health interventions that truly help patients but may not be on “the list” of what’s covered (or perhaps be reimbursed so minimally that a provider may be able to make more by doing something else for their patient that may be clinically necessary or questionably necessary or even not so necessary).  But what about the personal motives of individual providers, owners or investors of health care services, such as greed or inability to compete effectively in the local market because other providers can manage this dilemma differently due to their sheer size or their focus on high volume care providing?  It’s complicated.

When you look at your Explanation of Benefits (EOB), and you see that the hospital at which you had your total knee replacement surgery charged your insurance well over $100K, realize that they will not be paid that amount because your insurance is never going to pay that amount in the current insurance based provider environment that is constantly complicated by operational budgets and profit motives of human beings (whether as an individual provider, a professional group of physicians or PTs, or a mega-huge research hospital system with very, very deep pockets) as well as the sheer demand for health care services and high cost of health care technology and innovation.  All of these forces are in play.

I’ve been in practice for over 30 years.  I’ve seen so many changes that have impacted this discussion but they are almost always triggered by insurance based reimbursement policy.

The presence of fraud, waste and abuse in healthcare has been well-established for many years, is a direct reflection of the forces mentioned above, runs directly counter to professional ethics in healthcare and accounts for Billions of dollars of unnecessary expenditures each and every year.₂

I don’t know if you’ve noticed, but our healthcare delivery systems in the USA are becoming more and more consistent with the Big Box store models of operation where BIGGER generally means being better able to compete and, let’s face it, control business revenues and costs.  But are there tradeoffs involved, especially to the patient and the care they receive?  Most notable among potential tradeoffs to the patient is whether a provider refers you only to a PT Clinic owned by the referring provider or group of investors as opposed to referring the patient to where the patient prefers to go.  I can tell you very honestly, we see this on a daily basis and our patients often tell us that they had to fight with the referring provider’s office to actually have their referral redirected to us even though they made it clear to their provider where they preferred to be referred for their PT.  While it is not always the case, this general practice by providers might actually be illegal as it relates to the principle of “referral for profit” (aka, “Stark Law”) and has a much different legal applicability for health care providers than it does most other types of professionals and businesses.  In South Carolina, the legal rules are very attractive to providers in that it is NOT against the law as the general premise so long as the referral meets pre-defined exceptions.3  While it may NOT be illegal, it may still be quite unethical.  This poses a substantial breach of standardized and more fair provider practice guidelines and good luck going through the Legal process of proving unethical referral or practice behaviors by those who fall into the “questionably ethical” group.

While it’s only one piece of this enormously complicated puzzle, insurance reimbursement policies have a significant impact on providers’ practice behaviors4 and play an immense part in this ethical challenge in America, which is often touted as having “the best health care system in the world” anecdotally.  The research does not support this claim when compared to other developed countries.5

We can definitely do better than this in America.  Our experience as providers has been that most health providers are generally good and honest people who have committed to being excellent providers of high quality care but may not always have the autonomy to make independent decisions about how to treat their patients clinically or to where they are “permitted” to refer them when additional care, such as physical therapy, is needed.  Do your homework and choose wisely when contemplating where you’ll go to receive your care and whom you Trust to coordinate that care.

We Can Definitely Do Better Than This in America!!!

1 “Medical Ethics – An Overview of the Basics” (found online at: https://vtethicsnetwork.org/medical-ethics/overview); Vermont Ethics Network, 9/20/2022.

2 “What You Should Know About Health Care Fraud, Waste & Abuse” (found online at: https://www.fighthealthcarefraud.com/); Fight Healthcare Fraud, 9/20/2022.

3 “Fraud and Abuse Laws” (found online at: https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/#:~:text=The%20Physician%20Self%2DReferral%20Law%2C%20commonly%20referred%20to%20as%20the,relationship%2C%20unless%20an%20exception%20applies); U.S. Department of Health and Human Services – Office of Inspector General, 9/20/2022.

4 “Discovering Healthcare Provider Behavior Patterns Through the Lens of Medicare Excess Charge” (Sen & Deokar: found online at: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05876-1); BMC Health Services Research, 9/20/2022.

5 “Mirror, Mirror 2021: Reflecting Poorly – Health Care in the U.S. Compared to Other High-Income Countries” (found online at: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly); The Commonwealth Fund, 9/20/2022.

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I Have ‘RADICULOPATHY’ and it’s Ridiculous!

By David P. Brungo, PT, Expert Contributor, Summerville PT & Balance Rehab for Adults

Many of my clients tell me they have burning pain, numbness and tingling, or just a feeling of weakness in their shoulders, upper torso, down their arms or into their hands and fingers, or maybe in their buttocks, portions of their thighs or lower legs, sometimes all the way down to their feet and toes. Just about everybody, I’d guess, has heard of the term, “sciatica,” but many people don’t understand what it really means. Sciatica is an ambiguous clinical term and an example of a RADICULOPATHY. This means the actual problem area is somewhere like the spine or other area like your hip wherein a nerve or multiple nerves are involved, but many of the symptoms are perceived in other areas. That is to say, some symptoms of a bulging disc or pinched nerve roots branching from your spine in the neck or back are felt in places other than the neck or back (i.e., some symptoms of the problem are not necessarily felt at the actual site of the problem — instead, they are radicular in nature and felt elsewhere).

A very important point to understand is that not all radicular symptoms are alike. The reason for this is simple: a bulging or herniated disc can push into different parts of the spinal cord and/or the spinal nerve root(s) that branch off the spine at that level(s). Sometimes a bulging disc pushes posteriorly into the spinal or central canal and puts pressure on the front margin of the spinal cord. Other times it can push more laterally and thus cause spinal cord symptoms that are felt elsewhere. But it’s not always a bulging or ruptured disc as the culprit.  Sometimes it’s an arthritic process called spondylosis in your spine that may cause your spine to crimp down on a peripheral nerve root that branches from the spine at a particular level due to a process known as spinal stenosis.  This problem would cause different symptoms.  Simply stated: it’s not a “one-size-fits-all” kind of thing when it comes to radiculopathies, so let the experts identify the problem so you don’t chase your tail thinking you’ve got it figured out.  You could be suffering needlessly.

Here is a really common example of a cervical (i.e., neck) radiculopathy and note that this is not intended to be an all-inclusive list of symptoms — nor a diagnostic recipe — just an example of a common clinical presentation along with typical treatment options:

Case Example:  Your symptoms include aching pain radiating down your right arm, numbness and tingling in your right thumb, index and middle fingers, noticeable weakness in your right arm and hand with a weak grip or handshake, and the reflexes in your right arm are less strong than they’re supposed to be when they’re tested.

Clinical Presentation Interpretation:  The above host of clinically tested signs (R arm weakness and diminished reflexes) and patient-reported symptoms (numbness, tingling, feeling of weakness in the right arm and hand/fingers) are consistent with a bulging disc pushing against the right side of the spinal cord at the base of your neck or perhaps peripheral nerve root compressions at the 6th and 7th spinal levels as these nerves branch off the spinal cord and pass through the foraminal “tunnel” spaces that are created by bony projections from each of the two adjacent vertebral bones.  These tunnel spaces can get smaller and smaller and eventually irritate if not compress the nerve roots at those levels due to spinal stenosis or degenerative disc disease (DDD).

Treatment: That depends on the nature and severity of your signs and symptoms. Conservative treatment should include physical therapy for traction, stretching and postural retraining with the goal of reducing or eliminating the bulge of the bulging disc or to relieve pressure on the peripheral nerve roots that are being irritated so as to reduce or eliminate the patient’s symptoms as quickly as possible in the short term, but as well keeping it that way for the long term via the process of skilled interventions that improve posture and overall spinal alignment in the neck.  More advanced cases might be treated with steroid shots to reduce inflammation and pressure on the nerve roots in conjunction with physical therapy for longer term improvement.  The worst cases usually require surgery, like removing the bulging disc and potentially needing to fuse that level of your spine, after which the patient pursues optimal outcomes through physical therapy.  However, technology and technique advancements are providing better, less invasive options that don’t always require sacrificing some movement due to a permanent spinal fusion.

In my 30+ years of experience treating adults, the best outcomes are usually associated with timely identification of the problems, a highly motivated and compliant patient and working collaboratively with highly skilled medical and rehabilitation pros, such as your Orthopedic doctor, Neurologist and Physical Therapist.  Pain Management experts are often involved and instrumental in reducing the severity of symptoms, which can really go a long way to buying time before needing to consider more advanced interventions.  We’re also learning more and more about the potential benefits available from holistic practitioners such as most Chiropractors, Massage Therapists and Acupuncturists.

Fortunately, there’s a lot of really good help out there!

One thing’s for sure, though – it’s never a one-size-fits-all kind of thing, so resist the temptation of making self-diagnoses because you know someone with similar symptoms, and don’t wait until you can barely sleep or stand up straight or tolerate your work due to your symptoms.  If you’re experiencing symptoms such as those described above, you may be suffering from a cervical or lumbar radiculopathy and should follow up with your doctor or favorite PT sooner rather than later and get started on the work involved in fixing the problems before they advance to the point of having very limited options.

It doesn’t have to be ridiculous!

 

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May242018NOCOMMENTS

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Publications, Your Health

Arthritic Knee Pain? Here Are Your Options!

By David P. Brungo, PT, Expert Contributor, Summerville PT & Balance Rehab for Adults

I’ve been a PT for nearly 30 years and one of the most common conditions I’ve seen is wear and tear arthritic knee pain (aka, osteoarthritis), and for good reason.  Our knees take a beating over the course of our lives and we all are different with respect to how our knees hold up over time.  We’re genetically predisposed to some things that work against us, such as our bone density and joint anatomy or propensity toward disease processes like obesity, kidney disease, high blood pressure or hormonal imbalances that we inherit, others are activity related, such as trauma from injuries or repetitive stress (e.g., an automobile collision, a football or cheerleading injury, a fall from a ladder, etc.), and of course some are lifestyle related, such as the destructive effects from long term smoking or alcohol, an unhealthy diet or inadequate level of exercise.

We’re all different with respect to the portfolio of variables we each have that contribute to our knee arthritis and, likewise, we each perceive and experience things differently as well as respond uniquely to the various ways for us to manage or treat the problem.  We’re all different – managing knee arthritis is not a cookie cutter activity and there is no valid “apples to apples” comparison that we can use to gauge how we will experience, for example, a total knee joint replacement surgery compared to others who have had the same procedure.  Yet, we do this all the time and it can really impact our decision to seek the most effective care in a timely manner.

There have been a lot of great advances in how knee arthritis can be managed.  Newer medicines and improved surgical procedures and materials have developed with some really promising emerging interventions getting a lot of attention, too.  And we’re learning more and more about how our lifestyle choices contribute to the big picture.

I believe the best patient outcomes are typically associated with patients who are best informed about their options when it comes time to do something about their knee arthritis.  Thus, it’s imperative to do your homework.  I’ll try to make that a little easier here.

Let me start by saying this:  There is no magic pill – at least not yet!  You will have to work toward a successful outcome and yes, pain is part of the equation but you should never be asked or expected to work beyond your tolerance. 

 

Fortunately, there is no shortage of information available to us when we’re ready to do some homework so look for a credible resource that does a really nice job explaining the nitty gritty and summarizing your options.  For example, according to WebMD, the primary goals of treating osteoarthritis of the knee are to (1) relieve the pain and (2) maximize normal and healthy mobility.  Successful outcomes will typically include a combination of the following:

Weight loss:  Losing even a small amount of weight, if needed, can significantly decrease knee pain from osteoarthritis.

Using assistive devices or braces:  Using a cane or a walker may be necessary to provide more body support while standing or walking.  There are generally two types of braces: “off loader” braces, which take the weight away from the side of the painful knee; and “support” braces, which provide external support around the entire knee.

Exercise:  Strengthening the muscles around the knee makes the joint more stable and decreases pain. Stretching exercises are important to ensure that muscles are working at their optimal lengths, which helps keep the knee joint mobile and flexible with the least amount of inflammation from muscular imbalances.

Pain relievers and anti-inflammatory drugs:  This includes temporary use of over-the-counter (OTC) medications such as acetaminophen, ibuprofen, or naproxen.  If OTC meds don’t provide enough lasting relief, your doctor may give you a prescription for an anti-inflammatory drug or other medication to help ease the pain.  Examples of these include opioid meds (oxycodone, hydrocodone, codeine, morphine) and non-opioid meds (naproxen, topical lidocaine, meloxicam, celecoxib).

Injections of corticosteroids or hyaluronic acid (HA) into the knee:  Steroids are powerful anti-inflammatory drugs.  Hyaluronic acid is normally present in our joints as a type of lubricating fluid.  Stem cell therapy is an emerging medical intervention that’s getting a lot of attention but may not have the robust, long-term analysis on its effectiveness on all the things we’d like it to fix, such as the entire joint surface with new and healthy bone covered in a beautifully thick layer of bone-protecting cartilage!!!  Sorry — we’re not quite THERE yet!!!

Alternative therapies:  Some alternative therapies that may be effective include topical creams with capsaicin, acupuncture or supplements, including glucosamine and chondroitin or S-Adenosyl methionine (SAM-e).

Physical and occupational therapies:  If you are having trouble with daily activities, physical or occupational therapy can help.  Physical therapists can help with keeping pain and swelling under control while teaching you ways to strengthen muscles, increase flexibility around your knee and work toward restoring lost mobility.  Occupational therapists teach you ways to perform regular, daily activities, such as self-care and housework, with less pain and sometimes incorporates use of assistive devices such as reachers or sock-donners.

Surgery:  When other treatments don’t work, surgery is usually your next option to consider.  If your doctor wants to treat the osteoarthritis in the knee with surgery, the options are arthroscopy, osteotomy, and joint replacement (arthroplasty).

Arthroscopy uses a small telescope (arthroscope) and other small instruments. The surgery is performed through small incisions. The surgeon uses the arthroscope to see into the joint space. The surgeon can remove damaged cartilage or loose particles, clean the bone surface and repair other types of tissue if those damages are discovered. The procedure is often used on younger patients (55 and younger) in order to delay more serious surgery.

An osteotomy is a procedure that aims to make the knee alignment better by changing the shape of the bones. This type of surgery may be recommended if you have damage primarily in one area of the knee.  It might also be recommended if you have broken your knee and it has not healed well.  An osteotomy is not permanent, and further surgery may be necessary later on.

Joint replacement surgery, or arthroplasty, is a surgical procedure in which joints are replaced with artificial parts made from metals or plastic. The replacement could involve one side of the knee or the entire knee. Joint replacement surgery is usually reserved for people over age 50 with severe osteoarthritis.  The surgery may need to be repeated later if the joint wears out again after several years, but with today’s modern advancements most new joints will last over 20 years.  Any surgery has risks, but the results are generally very good.  NOTE: Rehab following a knee joint replacement is hard work and an extended process that could take 3 – 12 months.  You’ll need to be prepared mentally for the process, which can be a bit of a grind but you will be glad you kept forging on with your head down while doing whatever you need to do to keep on taking steps toward the destination — a markedly improved Quality of Life with no more knee pain!  It does not have to be misery!

Stay in the Game by committing to regular exercise and do your best to maintain a healthy lifestyle.

 

If you’re suffering with arthritic knee pain you should talk to your doctor about your options.  Your options should always be considered from a “big picture” perspective and typically will require diagnostic studies such as blood work, xrays and of course a thorough medical and physical examination that considers, among other things, your medication history, diet and lifestyle.  Once you and your doctor decide which path you will take, it’s likely that you’d benefit from physical therapy whether your plan involves surgery or not.  Exercise is critical and working with a physical therapist has been shown to be highly effective in managing knee arthritis before and after surgery and will help you achieve optimal functional results and maximum Quality of Life!

For more information, see: Osteoarthritis of the Knee (Degenerative Arthritis of the Knee) (found online at https://www.webmd.com/osteoarthritis/ostearthritis-of-the-knee-degenerative-arthritis-of-the-knee#1; May 19th, 2018).

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