“Hypocrisy is the act of pretending to have beliefs,opinions, virtues, feelings, qualities, or standards that one does not actually have. Hypocrisy is thus a kind of lie. Hypocrisy may come from a desire to hide from others actual motives or feelings.”
We’ve come a long way since March 5, 2009. That was the day of the first “summit” on health care reform. Oh, I remember it well. All the stakeholders, all the players, were so excited to be a part of the summit, a part of the process.
It was an exciting time. Until the stakeholders realized that the promise of reform was for real.
The stakeholders that have the most to lose are now spending millions of dollars to cover their reform-exposed asses. I think the last number I read was $1.4 million per DAY from the big money stakeholders. It’s Big Pharma … Big Insurance … Big Hospitals … Big Medicine …
I hate to admit, but the heat has gotten to me a little earlier than usual this year.
So far this spring and summer, Austin has had something to the effect of 32+ days over 100 degrees. The typical annual average? Eleven. Holy Heatwave, Batman, this has been one hot summer thus far - and we're barely past the solstice!
With that in mind, I thought it would be appropriate to post a few thoughts about the heat - and, specifically, training in these dastardly conditions.
You've probably heard the names before ... Big Pharma (the pharmaceutical industry), Big Tobacco (the tobacco industry), Big Oil (the oil industry) - and the list goes on. The one thing that all of these industries have in common is a hefty budget for political lobbying and lobbyists.
Let's face it - money and power tend to go hand in hand, and this is exemplified in our legislative process on a local, state, and federal level. Everyone has a political action committee these days. Any and every group that wants to get something done in Washington (or Austin, or any other state capital) has a wing of their group responsible for political action dollars and political campaign contributions.
But with money comes ... bias. Bias is defined as "a term used to described a tendency or preference towards a particular perspective, ideology or result, especially when the tendency interferes with the ability to be impartial, unprejudiced, or objective". Examples of bias - and the impact of that bias on decision-making, can be found everywhere. There is a science version ... and there is most definitely a political equivalent. Much as bias clouds a researcher's ability to draw fair and reasonable conclusions from the data, political lobbyists and financial interests cloud the ability of the legislator to make sound constituent-based decisions.
Gone are the days in which a legislator can truly make a choice based on the needs of his/her constituents. Though they would like us to believe that they can accomplish this, it's become exceedingly hard to believe, especially when you watch the voting patterns of legislators based on who contributes to their political campaign.
Health care already has one of the "Bigs" - Big Pharma. The pharmaceutical industry is a significant political campaign contributor. We're constantly reminded that it costs a lot of money to do pharmaceutical research, which gives them a little slack in the public eye. But when pharma-sponsored research employs ghostwriters , when pharma-sponsored trials rarely produce results that are unfavorable to the companies’ products, when it becomes an issue of researchers having a financial conflict of interest - you really have to wonder where all of this is leading - and how it can possibly benefit anyone but, well, Big Pharma.
A prime example is the research done on Vioxx. From the New York Times (4/2005) :
Dr. Lisse said that while he was listed as the paper's first author, Merck actually wrote the report, an unusual practice. "Merck designed the trial, paid for the trial, ran the trial," Dr. Lisse said. "Merck came to me after the study was completed and said, 'We want your help to work on the paper.' The initial paper was written at Merck, and then it was sent to me for editing."
Where is the accountability? And what happens when Big Pharma has a hefty financial political lobby?
Another fine example that is close to home is the legislation for a smoke-free Texas. Now I know that some will be up in arms about how it's their right to smoke. But the evidence is overwhelming: the risks of smoking are well-documented, and we know that the overall long-term health care costs for this population are elevated. So should the non-smoking population be subjected to the known risk of second-hand smoke, and should they be expected to pay for the inevitable medical bills of the smoker (associated with the risk) when they do in fact occur?
As noted on May 19 by Brendan Burns of the Lance Armstrong Foundation ...
"It is with deep regret we inform you our bill to make Texas smoke-free has died at the hands of big tobacco. While nearly 70 percent of Texans support this measure and there are more than 85 co-sponsors in the Texas House and Senate, we have been unable to gain enough votes in the Texas Senate and the bill has been withdrawn. Big tobacco, their 40 paid lobbyists and millions of dollars might have won this battle, but the fight will go on."
Sound increasingly familiar? It has nothing to do with what is right ... nor how many legislators have known someone that has had or died from cancer. This is a high profile item nationwide ... and it still leaves the same bad taste as Big Pharma.
So we've discussed two of the Bigs: Pharma and Tobacco. But would you ever think of ... Big Medicine?
They are about to be front and center - in a plethora of ways. Let's start with the big ticket item: health care reform. Last week, the "stakeholders" in health care reform all decided to propose some solutions to the current health care issue. Funny how these are the same people that were almost violently opposed to it in the early 1990s. But now that public opinion and consumerism (and perhaps even an awareness of what works in other countries - like France ) have been thrust upon them, they are overjoyed to be taking part in the process. Suddenly they can save the country 1.5% per year. Where were they in 1994?
But behind the virtue of the concept lies ... a political campaign contribution.
The
issue of lobbyists for BigMedicine (tag-teaming with BigInsurance)
"running the show" can be heard loud and clear on this Bill Moyers
Episode:
http://www.pbs.org/moyers/journal/05222009/watch.html
Here are some examples of his interview with Donna Smith (community
organizer and legislative advocate for the California Nurses
Association), from the show transcript:
BILL MOYERS: Now, you must have an opinion as to why that is. [why single payer advocates had to protest to get a seat in the discussion]
DONNA SMITH: Because they've already made a choice. They've already made a choice, I think, to stay with the moneyed interest, the people who fund the campaigns, the people who fuel the government system as we know it now. You know, certainly where Senator Baucus is concerned, he's the third highest recipient of donations from the health insurance and health care industry in general. The third. The highest Democratic recipient. And sometimes I feel so strongly that he ought to have to disclose that at the beginning of every single hearing that he chairs.
BILL MOYERS: But he says, of course, "That doesn't affect my judgment. This doesn't affect my decision."
DONNA SMITH: I don't think I'd buy that. And I don't think there's very many people in this country that would buy that. If you have someone who's giving you money to insure that your position to stay in a very powerful role in the United States Senate - that's a prime position politically.
I sat in a committee meeting with some staff members of Senate Finance some time ago. And somebody gave this argument, it's not politically feasible to do single-payer. So many people who will say, "Don't let the perfect be the enemy of the good."
And I think, well, that's an interesting analogy, acknowledging that the perfect may be single-payer but that you can't do it 'cause it's politically not feasible. So I sat there and I let this person talk. And he said, there's a visceral reaction to single-payer.
And I let him talk for a minute. I said, "From whom? Who's the visceral reaction from?" The Congress, he said, because elections are reality. These people have to run for new terms every so often. The money and the power that's exerted in Washington on them from the health insurance and health industry lobbies is very powerful. It's hard for them to break out of that loop. It takes an awful lot of nurses and doctors in the streets and being arrested, apparently, and more than 60 percent of the American public to say to them, "We're behind this. This is what we want you to do."
So there is a lot of financial bias being dished out by "the Bigs". But don't think for a minute that it's just a federal issue.
To show you the impact of health industry lobbyists and political action committees on a statewide level, the Texas Medical Association alone has 26 paid lobbyists registered with the Texas Ethics Commission. That is almost as many as Big Tobacco in the state of Texas. Irony of ironies though ... the Texas Medical Association was in support of the smoking ban - perhaps one set of Big lobbyists were overwhelmed by another set of even Bigger lobbyists?
And that, dear reader, is exactly the point.
I do still believe in the role of government and representation by the people. for the people. This can not be accomplished with lobbyists running around throwing million dollar budgets at legislators. Sure, the dollars must be disclosed through entities like the Texas Ethics Commission - but what might prove more interesting is to know what the PACs are representing, and who they are paying.
And on that note ... the next article will discuss the ramifications of these PACs on health care in states such as Texas and California - and how these entities have a significant impact on your health care.
Updated 4/2/2009: see below
Further discussion and information can be found in the forum here .
Here is a rather distressing piece of information that I read this morning:
1 of every 4 Texans is uninsured.
That's a rather humbling and disheartening statistic. With that in mind, our health care system needs to continue to seek out ways for patients to get the care they need, when they need it, in a cost-efective manner.
Direct access to physical therapy can help contribute to the solution. By removing one additional step in the process of attaining the necessary care, Texans can save a significant amount of money. Health care costs will drop, and this will help everyone - insured and uninsured.
Take a moment to ponder why anyone in the health care system would oppose this. It's an issue of access, and cost savings - which are both good things for all Texans. Direct access has not been found to increase liability claims in states that have it. In the end, it's a winning proposal for all. But in the same breath, you also need to consider the forces that would oppose such legislation and the lobbyists that support them.
This issue shouldn't be about the lobbyists, and it shouldn't be about the powers-that-be with the not-so-well-hidden agendas of money and power that continue to tell us that they have the patient's best interest from and center. This is about access to appropriate health care. This is about a system that is financially strapped - for the insured and the uninsured.
And it's about you, the patient.
If you care about your cost of care, and you care about your access to care, then I would suggest one thing: it's time to write to your legislator in support of HB 607 and SB 433. By speaking out, we can all benefit.
Update 4/2/2009: Texas Medical Association reports on their website that Texas ranks #43 of 50 states for a "shortage of physicians, both primary care physicians and specialists". There aren't enough physicians in the state, and they are not supporting direct access to physical therapy to provide improved access to care. Is this about the consumer? Again, you make the call.
Texas HB 607 and SB 433 are, simply put, consumer access bills. They don't change the scope of practice of physical therapists (i.e. what they can and cannot do as part of their clinical practice). These bills simply remove the current gatekeeper status of physicians. As it currently stands, physical therapists in the state of Texas are the only health care providers remaining that require a referral from a physician. With this having a direct impact on access to care and cost of care for consumers, it is important for everyone to write to their representatives in the House and Senate to support these bills. I sent the following letter to all members of the House Public Health Committee and the Senate Health and Human Services Committee this past week.
I am a physical therapist in Texas and am writing to you in support of HB 607/SB 433. This consumer access bill would allow Texans direct access to physical therapy services without a referral by another licensed healthcare provider.
There are three primary reasons to support this bill:
Cost: The current regulatory practice - allowing doctors to be gatekeepers to physical therapy in our State - adds enormous costs and waste to our health care system. The added costs are not just to Texans as individual consumers, but also to the State of Texas in Medicare costs. As but one example, a 1994 study by Mitchell and de Lissovoy noted that the total paid claims for "physician referral episodes of care" averaged $2,236, as compared to $1,004 for "direct access episodes". Data such as this has existed for the past 15 years. As costs have continued to skyrocket since then, there is a need to move forward with a regulatory practice that will provide more cost-effective care to all Texans.
Access: The current regulatory practice creates a barrier to health care for Texans. The reality of clinical practice is that when patients are faced with a choice to either 1) go to a gatekeeper (in order to then be referred to a physical therapist) or 2) simply not go at all, they tend to choose the latter option. This creates chronic situations out of acute ones. An acute problem that can be dealt with in a very short period of time can now become a chronic issue that yields years of health care expense.
Training: Physical therapists are internationally recognized as experts in therapeutic exercise prescription. The educational process is extensive and on-going. Under the current regulatory practice, a patient can be advised on therapeutic exercise prescription by virtually any healthcare provider and even personal trainers (none of which have any formal training in therapeutic exercise) - yet a patient requires a gatekeeper referral to exercise the option to see a physical therapist (a healthcare provider who's primary educational background is in therapeutic exercise prescription).
HB 607/SB 433 does not expand the physical therapy scope of practice, nor does it affect the current statutory duty to refer to a healthcare professional for conditions outside of the scope of practice of a physical therapist. The evidence from states that have updated their physical therapy practice act shows that allowing citizens to access a physical therapist without a referral has not negatively impacted liability claims.
I believe it is time for Texas to make a change that benefits all Texans. I would like to thank you in advance for your support of HB 607/SB 433.
If there is any way that I can be of assistance or provide further information regarding this issue, please contact me at 512-914-0871 (email This e-mail address is being protected from spambots. You need JavaScript enabled to view it ), or the Texas Physical Therapy Association at 512-477-1818 (email This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
Sincerely,
Allan Besselink, PT, Dip.MDT
Director, Smart Sport International
As I bring this issue to the attention of the consumer, many are absolutely surprised and dismayed that the current regulations exist. For those who have been to physical therapy in the past, they have experienced delays in their care; for those that haven't, they are upset that they don't have the option to access a physical therapist directly - for both issues of access and cost.
For further information on these bills, please refer to my previous post. If you support these bills, please take action! Legislators need to hear a strong voice from their constituents to overcome the political inertia of medical lobbyists.
In the state of Texas, you can't see a physical therapist for treatment without a referral. It's the law - plain and simple. It doesn't matter what your insurance company says regarding your particular "referral requirements" because that relates specifically to whether or not they will reimburse for your treatment (or not).
Seeing a physical therapist as a first line of health care and assessment is an accepted standard internationally, in many other U.S. states - and even within our own military. But not in Texas.
So here's the crazy reality of this long-outdated regulatory practice.
Let's say you have back pain … or an ankle sprain … so here are some of your current options:
You can see a massage therapist - who may provide some form of exercise program - though massage therapists have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.
You can see a chiropractor - who may provide some form of exercise program - though chiropractors have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.
You can see a physician - who may provide some form of exercise program - though physicians have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.
You can see an advanced nurse practitioner - who may provide some form of exercise program - though nurse practitioners have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.
You can even see a personal trainer - an unregulated and unlicensed occupation - who may provide some form of exercise program - though personal trainers have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.
Under the current law, you can go to any of these "providers" - all having little or no formal training in therapeutic exercise prescription. But if you want to go to a physical therapist - the internationally accepted "experts" in therapeutic exercise prescription - you have to have a "gatekeeper" (the list includes physicians, dentists, chiropractors, podiatrists, physician assistants, and advanced nurse practitioners) approve it first.
This is where Texas House Bill 607 and Texas Senate Bill 433 come into play. Both of these pieces of legislation have been filed to provide direct access to physical therapy in the state of Texas. Both are consumer access bills. Neither change the scope of practice of physical therapists in the state of Texas, but they do eliminate the current "gatekeeper" scenario that limits a patient's access to care.
The available evidence squarely supports direct access for physical therapy. Here are the reasons why:
1. As I mentioned previously, physical therapists are internationally accepted as "exercise experts". Our training is focused on the use of therapeutic exercise in the treatment of disorders of the musculoskeletal and neurological systems. Physical therapists have the formal training and education to make functional and mechanical diagnoses for our patients. This is the reality. It is part of our task as physical therapists - to evaluate, to assess, to establish a plan of care. Physical therapist professional education prepares us for autonomous practice, and it is already a part of our current scope of practice.
2. Do physical therapists have the training and education to establish "red flags" in the patient's history, assessment, or treatment that would indicate that physical therapy is not appropriate? This is also an absolute YES. Once again, this is part of our current day-to-day patient care responsibilities. We must be able to decide when it is safe for a patient to participate in physical therapy, and when they must be referred elsewhere. The difficult cases, the ones that need further diagnostic work-up, are typically NOT the ones that are going to see a physical therapist first - it's those that have conditions like neck and back pain and sprained ankles, issues that - in the literature - respond readily to self care strategies and therapeutic exercise prescription from a qualified practitioner. Studies have shown that there is no increase in the incidence of any medical problems in direct access states. Again, physical therapist professional education prepares us for autonomous practice, and it is already a part of our current scope of practice.
3. Access to health care is an important issue in our health care system. You currently have to go to a gatekeeper for a referral to physical therapy. This currently adds at least one extra step in the process of a patient receiving timely and effective care that is appropriate to their condition. When given the option to go to a physician first, then to a physical therapist - or simply not bother "jumping through the hoops" (both in cost and in cumulative time), they will oftentimes resort to the latter option, and not get any care at all. This is a barrier to care, making an acute issue a chronic one.
4. Last but certainly not least, there is the cost of care within the current regulatory practices. By adding more steps to get to the appropriate provider, we are creating more barriers to care for the average health care consumer. This "referral" process creates greater costs for the patient and/or insurance carrier. First you pay your "referring provider" (i.e. physician) for him/her to then send you to a physical therapist, who you will then pay to provide therapeutic solutions to your problem. Why have this extra cost involved? Studies have shown that there is a direct cost benefit to the consumer by seeing a physical therapist as the first line of assessment. This cost extends not only to the individual but to the state's Medicare system. It has been estimated that there would be a savings of $1200 per patient episode of care - or 55% of the total cost.
So if all the evidence leads us down this path, why is this not the accepted standard of care for all Texans?
This is where we must simply face the harsh reality of our current regulations. There is no evidence that in countries (or states) that have direct access, the cost of care has shown a dramatic increase or a higher incidence of medical problems requiring further medical intervention. As a matter of fact, it's the opposite. Opponents of more effective legislation are not necessarily driven by patient safety, nor access to care, nor cost of care. So what drives this resistance?
It's not about the patient - and we need to simply stop letting this fallacy be proposed to the public, the legislature, and the media. The primary parties lobbying against this type of legislation are typically physicians and chiropractors, and it is, in all reality, driven by two things: dollars and cents - and power.
Why do these "powers that be" not want physical therapists to have direct access when all of the data supports it being beneficial for the patient and for access to cost-effective health care? Referring sources such as physicians and chiropractors feel that it is not in their best interests financially to have this take place. "It will drop my bottom line" … "It reduces my power as a gatekeeper" … etc.
But as health care dollars grow scarce, and the demand for evidence-based medicine expands, the days of money and power are gone. The gravy train has left the station. The current medical climate forces everyone to be "on their game", to be a provider that a patient would want to utilize to help solve their problem in a cost-effective and timely manner. In order for our health care system to move forward, it is time for all of us to put our best foot forward and foster a medical system that is truly patient-centered.
Let us not forget, it IS about the patient. It IS about your consumer access to health care. And it IS about the cost of your health care.
What can be done? Speak to your state representative and your senator - they work for you - not the lobbyists. Write letters. Do the reading and understand the issues. And support House Bill 607 (Farabee) and Senate Bill 433 (Carona).
For some supplemental reading, refer to the following:
http://murphy.house.gov/News/DocumentSingle.aspx?DocumentID=61988
http://murphy.house.gov/UploadedFiles/HealthCareFYI?53.pdf
http://www.house.state.tx.us/members/dist69/farabee.php
http://www.senate.state.tx.us/75r/senate/members/dist16/dist16.htm
And while we're at it, how about a few videos to help ilustrate the point - one serious, and one slightly more tongue-in-cheek:
"Get your facts first, then you can distort them as much as you please." (Mark Twain)
If the American public knew what was going on in the undercurrents of their health care, I don't think they'd stand for it much longer. Regardless of whether you have insurance or not, if the average person was a better consumer of their health care, they would demand accountability. They would demand results. And they would do so just as they do with any other free enterprise industry.
First of all, it doesn't matter whether the care is good (outcomes-driven and evidence-based) or not, your insurance carrier is likely going to pay for it. What is currently accepted in our community may not in fact be a part of any accepted clinical guidelines, or, worse yet, it may be totally unsupported in the scientific literature. Though we are finally seeing some examples of “payment for performance” (something I wrote about here in 2007), the third party payment issue produces a potential level of mediocrity, whether we like it or not. Is there any reason to do what is best when you're going to be paid regardless of what you do?
Second of all, this is another issue of trust. For years, we have gone on the assumption that the one person you can trust implicitly in your health care is your primary care provider. Why not? These gatekeepers are the revered ones, and thus we believe that what they do for us is in our best interests. The same is true of specialists like orthopedists. “Of course they will do what is best for us” ...
Allan Besselink, PT, DPT, Ph.D., Dip.MDT has a unique voice in the world of sports, education, and health care. Read more about Allan here.