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Neuromusculoskeletal Care

Physical therapists can, and should, help those in pain manage their symptoms to decrease addictive drug use.

By Heidi Jannenga, PT, DPT

I believe that physical therapists are the most qualified, most appropriately educated health care providers to treat patients with neuromusculoskeletal pain, injuries, and issues.

I believe it! I’m pretty sure you all believe it. So, why don’t other health care providers, payers, or your average person on the street believe it?

Did you know that 90 percent of people who experience a neuromusculoskeletal condition that we as PTs are well equipped to treat never make it in to see us? While a meager 10 percent receive physical therapy, the vast majority are still consistently traveling the path of opioid pain medication, steroid injections, surgery, or just plain old suffering.

Given that existing data is overwhelmingly supportive of first-line physical therapy intervention as a lower-cost and incredibly effective treatment path for common conditions such as low back pain, the fact that the vast majority of people with those conditions will never see a PT is more than tragic; it’s unacceptable. But I believe a national crisis has opened a door for our profession to take a long-awaited leap forward if we are willing to get our acts together and move quickly and cohesively.

The way I see it, we’re failing a huge portion of the population that we entered this profession to help. Not only that: We are doing a disservice to ourselves as colleagues as we continue to fight over the same 10 percent of people, rather than focusing on the bigger slice of the pie. To put that slice into perspective, the 10 percent of patients who need and receive PT encompasses about 11.7 million people in the United States (according to data from the Medical Expenditure Panel Survey and Bone and Joint Burden).

That means, if we can move the needle forward by another meager 10 percent, we’ll have another 11.7 million active patients to serve. Based on our market research, there are around 35,000 PT practices in the US today. So, that 10 percent bump would be 335 more patients per practice!
But as it stands, the vast majority of people—including potential patients—don’t know who we are, what we can do, or why they should see a physical therapist first. If they did, they surely wouldn’t be putting themselves through risky, expensive surgeries or filling prescriptions for dangerously addictive painkillers.

All this time, we’ve been trying to convince referring physicians of our value with anecdotal evidence and boxes of donuts, so that they could properly prescribe PT to patients in pain. And while the needle has moved—more MDs are aware of the benefits of physical therapy and are developing mutually beneficial relationships with PTs—it’s definitely not enough. We must do the work in our own practice settings to follow through on our promises. But the data shows we are missing the mark—with 70 percent of patients dropping out of PT before completing their plans of care. That’s unacceptable.

We’ve been screaming at payers that they’re undervaluing our care and not paying us enough to thrive. And we’ve been in-fighting and undercutting other noninvasive care providers, as well as each other, in a race to see who is willing to accept the lowest rates of payment—all the while worried that we won’t get our fair share of the patients who do understand our value and will actively seek out our care.

We’ve retreated into our own battle camp and waged war over the 10 percent. Meanwhile, the other 90 percent of patients who need us, but don’t know it yet, have been left out in the cold to fend for themselves in a health care system that has been relentlessly pushing dangerous drugs and unnecessary procedures for far too long.

All of this needs to stop now! The harmful repercussions related to the existing opioid epidemic are impacting lives on so many levels. We have a once-in-an-era opportunity to undo the damage that has been inflicted and to ensure that moving forward, people who are dealing with pain have everything they need to make educated choices about their health care—choices that are supportive of their overall well-being as individuals, not numbers or dollar signs.

Ready for some more data? In 2017 alone, 72,000 people died from an opioid overdose. One in four patients who receive prescription painkillers on a long-term basis for noncancer pain in a primary care setting end up struggling with addiction.1 And those who are addicted to prescription opioids are 40 times more likely to develop an addiction to heroin.2 In other words, we’re talking about an incredibly slippery slope for patients who are unnecessarily prescribed pain medication. And we’re—at least in part—responsible for that.

Last fall, my company, WebPT, hosted its fifth annual Ascend conference in the heart of Phoenix, Arizona. There, David Elton, the senior vice president of clinical programs at Optum and a member of the UnitedHealth Group’s Opioid Task Force and Pain Management Work Group, provided the keynote address.

He laid the foundation for an open dialogue between rehab therapists and one of the largest insurance payers in the business: UnitedHealthcare (UHC). He entered the Thunderdome.

And he came armed with his own data: a study by Boston University—jointly sponsored by UHC and the APTA—revealing that many patients with something as common as low back pain have been prescribed pain meds at an alarming rate, despite the fact that low back pain patients who access conservative therapies such as physical therapy first are “75% to 90% less likely to have short or long-term exposure to opioids”—75 to 90 percent!3

In fact, according to Elton, claims for musculoskeletal episodes accounted for more than 16 percent of UHC’s total spending—a percentage greater than that associated with any other condition.

To put that into perspective, a little over 11 percent of UHC’s total spend went toward claims for cancer treatment. Furthermore, out of all the money spent on those musculoskeletal episodes, 75 percent went toward prescription medications. In other words, UHC has been spending more money on prescription medications to treat low back pain than they have spent on treating cancer.4

Clearly, the system is broken. But this is not a time for finger-pointing. It’s a time for action. Out of crisis comes opportunity! Solving this issue is of course going to require insurance companies to support a change and incentivize different clinical pathways for these patients. But we also have to step up to the plate and be willing to take on this opportunity and deliver.

I believe that to change our landscape, we have to go straight to the source. We’ve got to reach patients through direct access—and we’ve got to do it now, in this small window of time when everyone is paying attention to the prescription painkiller epidemic. There are more than 200,000 physical therapists practicing in the United States.5 That’s a force to be reckoned with—as long as we’re a force moving in the same direction.

Instead of splitting our energies, dividing ourselves by specialties within specialties, our profession must unite today—for the betterment of our collective selves and our patients’ lives. This truly is a life or death situation.

What if your mother, your child, or your best friend was seeing a physician who was about to recommend a treatment route that could lead to devastating consequences—but you knew there was a better option? Would you say something? Or would you remain silent in the shadows, thinking that it’s not your problem?

If you did speak up, what information and data would you provide to convince your loved one to put down the pain meds, walk away from the unnecessary surgery, and invest in his or her own future health and well-being? Even if it took a little more effort and perhaps involved a little more money spent upfront, wouldn’t it be worth having that important—and perhaps even a life-changing—conversation?

As it stands, physical therapy can cost more upfront for patients who have high deductibles and copays for specialty providers. It’s mind-boggling to me, but it’s the unfortunate truth. There are barriers to entry, but some of them are being addressed by payers like UHC. Specifically, UHC announced that it will waive the copay for a patient’s first three PT visits. This is definitely not a love-fest for UHC, and it’s not a perfect solution. But it’s a start, and it shows what can happen when all stakeholders are willing to come to the table and talk about finding a better way.
Of course, even if patients are paying out of pocket for the therapy care we provide, it’s still a significantly better investment in their long-term health than choosing something that could have not only dangerous, but also extremely expensive, long-term detrimental consequences.

The problem is, humans don’t tend to prioritize the long term. We’re all looking for the quick fix, the instant gratification, the magic bullet. Let’s face it: We as a society are lazy and want the pill or surgery that will free us from pain and get us back to our regular lives as soon as possible.

As therapists, we know better. We know that none of those options work. We know that short-sighted decisions about one’s health have irrevocable consequences (and I think, based on recent events, insurance companies and other health care providers are more readily agreeable now, too). So, now’s our opportunity for all of us here today to help people expand their perspective beyond the immediate future.

This may sound cliché, but I believe we have the opportunity—right now—to change the world. And no, I don’t have all the answers. I don’t know what the message is going to be that’s going to convince John Smith and Jane Doe to #ChoosePT.

But I do know that everything starts with having honest conversations—and then taking inspired and unified action. Because—as I said before—now is the time for action; it’s the time for all of us to put ourselves out there, overcome our fears, regain our confidence, and effectively communicate the value of what we offer as primary care providers for patients with neuromusculoskeletal conditions.

To do that effectively, we must embrace all the things that we’ve historically shied away from: We must step up in business, marketing, technology, online optimization, standardized outcomes data collection and dissemination, standardized education, and standardized care delivery. And we must do this together—as a team, as a community. This only works if we all commit to upping our game to better serve our patients, who need us now, more than ever.

Everyone in this room is a thought leader in this industry and is therefore a model for others in our profession to look to. But can we think bigger? Expand our comfort zones? I can tell you it’s not easy to do. It took me more than a year to really come to grips with my transition from PT practitioner to PT software executive and entrepreneur. But what finally got me over the hump was to see that my purpose in life—to truly help people—could be exponentially broadened by stepping outside of what I thought my path needed to be. When the dust startled to settle, I realized I had the opportunity to not only help the patients I put my hands on but also my peers and their patients (as well as my industry as a whole). It was that epiphany that helped create our company mission to empower therapists to achieve greatness in practice—and garner 40 percent market share in 10 years. It took clear focus and purpose, and I know we can.

So, my challenge to you is this: Get honest—with yourself, your staff, and your peers—and start looking at where and how you can put a dent in this 90 percent. Stop underselling your value, holding back, playing small, isolating, or competing with others (for anything, but especially for the 10 percent of patients who are already seeing a PT). Then, commit to taking action to change—one thing at a time.

If all of us go home lit up, inspired, and determined to actively create a positive ending to this opioid epidemic once and for all, I have no doubt that our passion for this profession and our patients will spread. We’ll have our own task force—our own community—of exceptional PTs who will help those 90 percent of potential new patients return to their lives pain-free and fully functioning, without those patients ever succumbing to addictive drugs or risky procedures. I believe that changes the world. What do you believe?


References:

1www.cdc.gov/drugoverdose/epidemic. Accessed July 2019.

2www.cdc.gov/drugoverdose/opioids/heroin.html. Accessed July 2019.

3Technical Report – Conservative Therapies for New Onset Low Back Pain and Predictors of Long-term Opioid Use and Misuse. Lewis Kazis, ScD, et all. Boston University School of Public Health.

4ibid

5www.apta.org/PTinMotion/News/2017/8/7/100KMembersAPTA. Accessed July 2019.

Heidi Jannenga

Heidi Jannenga, PT, DPT, is president and cofounder of Phoenix-based software company WebPT, the country’s leading rehab therapy platform for enhancing patient care and fueling business growth, with more than 71,000 members and 9,800 clinics as customers.