Diane went to physical therapy under duress.
She didn't want to go.
Her insurance company made her go.
Her insurance company wouldn't pay for a Magnetic Resonance Image (MRI) for neck and back pain unless the patient had one month of physical therapy.
Can MBA's working for insurance companies practice medicine better than Medical Doctors and can MBA's practice rehabilitation better than Physical Therapists?
I don't know - they didn't call me to check before they hired the MBA's.
Anyway, Diane came to my clinic and went through the eval process.
I examined her head and neck posture, her trunk posture, her shoulder motion, her neck motion, her shoulder, neck and trunk strength.
I examined her nerve function...
Diane had normal nerve root signs (strength and sensation) but evidence of spastic and pathologic reflexes.
|Test Name||Result||Positve Likelihood Ratio|
|Hoffman's Test||positive||0.97 - 2.23|
|Knee reflex||hyper-reflexic (3+)|
|Ankle reflex||hyper-reflexic (3+)|
|Babinski's sign||downgoing||7.75 - 8.0|
"What are you doing down there?"
Why, you ask, would a physical therapist bother checking a knee reflex in a patient with neck pain?
Well, I say, it's my job - that's what I do.
So what's the big deal?
The point is that I called the doctor (the doctor's nurse actually) and told her the patient wasn't fit for PT.
The doctor's nurse was happy:
"We never thought the patient was fit for PT. We wanted an MRI the first time she saw the doctor. You've just given us ammunition we can use against the insurance company to get an MRI!I said you're welcome.
The patient was happy - she 'felt' that something was wrong, that physical therapy was inappropriate at this time.
The insurance company - were they happy? If they truly have the best interests of their benficiaries in mind then they should be happy - they are now paying for Diane's MRI because she has serious neck pathology - not just sore, weak muscles.
Cook et al state the following:
"Magnetic resonance imaging is considered the best imaging method becauseThe Source of Value
it expresses the amount of compression placed on the spinal cord and demonstrates relatively high levels of sensitivity (79%–95%) and specificity (82%–88%) (positive likelihood ratio (4.39–7.92) negative likelihood ratio (0.06–0.27) in identifying selected abnormalities such as space-occupying tumors, disk herniation and ligamentous ossification."
Value is a hot topic in health care today. Policy wonks around America want to find the source of value that will save health care:
Value = Quality / CostDid I create value?
I created value for Diane and for the doctor - I'm not sure that I created value for the insurance company because they have a different interpretation of quality.
The Question of Quality
Quality for Diane, the doctor and for me means the best outcome for the patient.
Quality for the insurance company means fewer PT visits, fewer episodes of care and fewer MRI's.
Quality also means determining which of your physical therapy patients DOES NOT need physical therapy.
Diane did not show Medical Necessity for Physical Therapy
When 40% of all Medicare denials are based on inadequate medical necessity it seems almost inappropriate to speak about those patients who DON'T need PT - when so many do.
What skill set is necessary to prove to Medicare auditors that what you do is necessary?
What do you need to write to show that your patient needs you?
This reference from the Medicare Benefit Policy Manual Transmittal 88 (page 26) is redundant, poetic, harmonic and true:
"Patients who need therapy generally respond to therapy, so changes in objective and sometimes to subjective measures of improvement also help establish the need for services."So, get on the stick, take measures, show progress and, above all, prove your value by demonstrating that no one but you, or another physical therapist, could do what you do.