A Conspiracy Of Silence - Part III: Health Care Utilization

"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” ...

And now, when you add these two issues together, you get our current system, which for many comes down to dollars and cents. There is a common phrase - “follow the money trail”. And there is plenty of evidence to indicate that our trust in the health care system is being betrayed – regularly. And it goes far beyond simply “what you practice and how you practice”.

So let's openly discuss another area of silence in health care: self-referral. We have laws in place – such as the Stark Laws – that govern physician self-referral. By law, there is an inherent conflict of interest to owning your own ancillary services like laboratories, imaging, and rehab services. With these laws in mind, there is an interesting game that is played in all of this. Physicians and chiropractors become “appointed” Medical Directors of these same services. The party line is that the addition of these services under one roof makes it more convenient for the patient, or allows the group practice to “provide the best services under one roof”. Of course, the concept of “bringing all the best services under one roof” sounds fabulous – and admittedly, the idealism of the concept can, at first, overshadow the “gray areas” of service utilization. In the specific sense of the law, are they “self-referring”? No.

But this can lead directly to the over-utilization of these types of services – and there is plenty of data to support this occurrence. Start with services such as imaging (x-ray and MRI) that are now being utilized as a first line of assessment. What is interesting is that in much of the orthopedic literature (and globally accepted clinical guidelines), this strategy is unsupported. MRI is over-utilized. The scientific literature supports this claim.

And if we go one step further, to rehabilitation services, they are over-utilized as well. Let's look specifically at the utilization of physical therapy. The primary care providers and specialists won't necessarily tell you that you have a right to choose your physical therapist, but, by law, they must provide this to you. More often than not, they don't give the patient options for their care. Of course, most patients simply don't want to go counter to the trusted authority of their provider, and yes, it sure does seem convenient from an insurance perspective.

The reality is that they do refer to a business in which they have a financial interest. This is why some regulatory bodies mandate that doctors declare their financial interest with clinics in advance.

Now, the numbers. The Journal of the American Medical Association reported in 1992 that patient visits were 39 to 45% higher in physician-owned practices, and that both gross and net revenues were 30 to 40% higher in the same physician-owned practices. In 1991, the state of Florida Health Care Cost Containment Board found that physician-owned physical therapy clinics provide 62% more patient visits per full time physical therapist, and 43% more visits for each patient. I have provided these references below.

Astounding? Yes.

If you are a physical therapist working in this type of environment, will the physician or chiropractor ever state “we need to see the patients more often”? Not in so many words – because that would be illegal. Do they ask “are we seeing them enough”? Or “could they be getting this or this as part of their treatment?” or “Do we need to follow up with them a little longer?”. Yes. And I can say that yes, I have experienced these “questions” as a PT working within both physician-owned and chiropractor-owned businesses. It wasn't overt, but the underlying inference and theme was definitely present.

Do physical therapist-owned clinics stand to lose dollars because of this? Yes. There is nationwide data to confirm this, and anti-trust horror stories that would make your head spin.

So yes, these issues are alive and well in our own community. The problem isn't just in someone else's community – it's right here. And it's affecting your health care – either with costs now, or costs with insurance premiums down the road.

But if you start to bring this to the light of day, beware of the power struggle that will invariably rear it's ugly head. Providers will go so far as to tell patients that you don't exist (even when patients tell them that yes, indeed, you do) – and yes, I know this happens. In my own backyard.

And what do you do if, heaven forbid, you are injured and now face this reality of having to be a consumer of your health care? And what if you are a runner that simply needs to get back to training?

That is the topic of my next article.

References regarding service utilization:

http://www.ptpn.com/insight/InsightJan06.pdf

http://www.mopt.org/pdf/bill109.pdf

http://www.ftc.gov/os/comments/healthcarecomments2/americancongress.pdf