Health care is in dire need of transformation. The system as we know it has been built on a foundation of principles that have conflicting values. Whether it’s the reimbursement models or the practice patterns, or both, the concepts of “quality” and “value” have been lost in the mix. What has become the accepted standard of care and delivery has become outdated, and in the midst of it, the patient – the driver of all of this – has been forgotten.

In any other realm, we look to quality and value as two key elements of an exceptional customer experience. A free and open marketplace fosters this. Consumers critically examine cost, quality of service, and results in their decision-making process for just about everything – cars, homes, education, you name it. Except health care.

Patients have learned to accept the gross failures and inadequacies of the health care system. Are patients satisfied with their care? Sure. But are their expectations of this “accepted standard” really at a high enough level? Or are they satisfied with something less simply because they have been told that that is the accepted standard?

This becomes all the more apparent in the world of physical therapy. When there are clinicians proclaiming that “first class service and results” create “the top physical therapy clinic for patient satisfaction” – and then stating that the “average length of stay is 10 visits – guaranteed” – I shake my head in disbelief. When 10 visits per course of care is considered “great care”, I have to wonder about what has become the accepted standard these days.

And there is plenty of finger-pointing by the clinicians at the insurance companies. It’s their fault for such low reimbursement rates, right? On the surface, there are many instances in which the finger-pointing may be well-deserved. But when you point a finger, as they say, four point back at you. The clinicians are as much to blame as anyone, and much of that has to do with a simple lack of innovation at a far deeper, systemic level. It starts with the clinician, their product, and their means of delivery.

Transformation requires a deeper level of understanding of the systemic problems, so let’s start there first.

Direct access to Physical Therapy still faces many barriers in the United States. Many of these barriers are simply not in the best interest of the patient, in that the current regulatory practice of a "referral" process to get to the appropriate provider creates greater costs for the patient and the right to immediate and effective care, a fact that patients simply do not understand.

As a physical therapist in Texas, I have watched the continued struggle with direct access to Physical Therapy. Texans can see a Physical Therapist for an initial evaluation, but cannot subsequently receive treatment without a physician referral. As a McKenzie practitioner, not having direct access is an enormous barrier to caring for our patients. With an assessment process that naturally shifts to treatment, we are faced with a dilemma. If the assessment reveals a directional preference, then instead of simply taking the next step and educating the patient regarding the importance of this, we must then interject "you need to see a physician for a referral."

In an era of “evidence”, there is plenty to indicate that direct access to Physical Therapy would increase a patient’s access to appropriate and necessary health care, decrease their cost of care and restore the patient’s right to choose.

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.

The phrase “evidence-based medicine” is pervasive in health care now. As the phrase becomes more and more common, there seems to be a growing chasm between those that utilize the scientific method, and those that don’t. It’s creating a rather intriguing problem for patients and practitioners.

In one corner, we have those that are utilizing evidence-based strategies in the care of the patient. Using the scientific method doesn’t eliminate what many call “the art of health care”. The clinician still has to have clinical reasoning skills (which are deeply rooted in the scientific method) and the ability to use their communication skills effectively to establish rapport with the patient.

In the other corner, we have the “gurus”. These are the people that will tell fellow providers that science has yet to explain what they do and besides, it doesn’t matter anyways. Experience is critical, and there are plenty of stunning anecdotal results that make it all the more obvious. The “gurus” are the ones armed with methods that have minimal scientific plausibility as a foundation. And when speaking to other practitioners eager to learn their “methods”, they will be the same people that will proclaim that one could be so lucky to attain their level of understanding, unless of course you want to take their 3 week course and pay a few thousand dollars to do so.

And though we might have once thought that the gurus were exclusively found amongst practitioners of “complementary and alternative medicine”, they are now rampant amongst “mainstream” health care providers (such as physicians and physical therapists).

But here’s the problem: you can’t live in a world in which you selectively choose when you want to live with evidence and science, and when you don’t. You cannot ride the coat tails of science while advocating for the cult of personality, mysticism, or the power of the placebo.

So do I need evidence? And why does it matter anyways?

Imagine this: more doping claims in the world of cycling. At this point, there are three things we can count on in life – death, taxes, and allegations of drug use in cycling.

The question has reared it’s ugly head once again: has Lance Armstrong been cheating all these years? Floyd Landis is the latest in a long line of people to point the finger at him. But before you even think of passing judgment, there are some rather important pieces of this puzzle that lend a great deal of context to what is becoming a made-for-TV-reality-show.Or a circus.Or both.

I’ll be the first to profess openly that I am a fan of cycling. I was introduced to it in my youth, and watching the Tour de France on TV has been an annual extravaganza that closely resembles March Madness in it’s ability to draw my attention. So it’s safe to say that I come into this discussion with a love of cycling.

I think it’s also safe to say that when discussing the issue of doping in cycling (or any other sport), we need to consider the context of the debate, the personalities involved, and the motives underlying the debate. We need to utilize the sports sciences research, and we need to examine our own belief systems. More on that later.

But back to Lance Armstrong. Over the years, Armstrong has faced accusations from a number of people that have been close to him in the cycling community.The most recent, Landis, has a rather intriguing and perhaps sordid tale. Here’s the storyline:

Not so long ago, in an infomercial or two, we were provided some of the finest observations of the state of the union – by none other than Ross Perot.

For those who have forgotten, while using his pointer and hand-held charts, he resolutely stated that “In America, we have a problem”. He may not have been talking about health care specifically, but he certainly could have been.

Consumers have somehow been lead down the garden path in the discussion of quality, cost, and access in health care (including allied health professions such as physical therapy, chiropractic, and alternative therapies). In any business realm that we can think of, our task is to find the greatest quality of product or service at either an affordable price, or a price that we feel is directly related to the quality of the service. But in health care, the system is currently driven by some very anti-consumer principles.

As Dick Cavett once noted, "As long as people will accept crap, it will be financially profitable to dispense it". Health care is no different. So what are the underlying mechanisms and motivators that are currently working against the health care consumer?

I have spent most of my career working with athletes, be they recreational or elite. They have run the gamut from endurance sports to power sports, and all points in between. Over 12 years ago, I completed the highest level of training in the McKenzie Method. Since then, I have been one of the few practitioners worldwide that has been actively applying this approach to a sports population.

With all of the approaches to care available, especially with athletes, why head down this path?

First of all, the McKenzie Method has a very intuitive “fit” with an athletic population. First and foremost, the active populace is typically in the “mind set” of self-treatment and training. Athletes, be they recreational or elite, seek treatment methods that are active and patient-centered. These patients are highly responsive to such measures and typically prefer approaches that facilitate “empowerment” and self-treatment.

The McKenzie Method also provides a great screening process – to understand the mechanical loading strategies, directional preference, and thus safe aspects of training that can be resumed early on in the injury recovery process.

The sports medicine world is traditionally very “pathology-driven”, so my first forays with McKenzie into this world were like speaking a foreign language.

If you want a fine example of where this country’s health care system is headed without reform, just take a look deep in the heart of Texas. It’s not a very rosy future. As I have mentioned many times before, the key elements to the discussion focus on cost, quality, and access – all issues of significant importance to Texans.

Let’s start off with some terrifying numbers. Consider this: 25% of the population of Texas are uninsured. Nationally, 20% of all Americans under the age of 65 are uninsured. As they say, everything is bigger in Texas. Ah but it gets better. The Austin American-Statesman has recently reported that 500,000 state workers – those with some of the best healthcare benefits in the state – are facing a $143 million deficit in their health care fund. That amounts to a budget increase of 14% over the next year. By 2015, the plan that provides health insurance for 193,000 retired public school employees will be insolvent. This all amounts to increases in premiums and greater out-of-pocket expenses for state workers. And when state workers are impacted (those that already have good health insurance coverage), what happens to those that have lousy or no coverage at all?

Along similar lines, Texas and California have the highest healthcare costs in the nation. In Texas, you might even be one of the 3.4 million people that forego treatment because they can’t cover the cost of care. This is second only to California, at 3.6 million.

Thus far, coverage is shrinking and costs are rising. That’s not a very healthy outlook. But, again, it gets worse.

I think it’s safe to say that the U.S. Preventive Services Task Force has opened an interesting can of worms recently at a rather inopportune moment. They have published what is, to my understanding, an evidence-based report on screening for breast cancer, including the use of mammograms. Emotional topic, without a doubt.

There have been some rather extreme responses as can often be expected when the discussion is driven by emotion. This discussion is taking place at a time when the current health care reform climate is volatile at best. People have already started proclaiming that “this is rationing of care – and exactly what health care reform is going to do”, “this will prevent women from getting the care they need”, and “hell yes, as a doctor I am still going to perform them regardless of what the study says”.

Let’s make sure that we understand the conclusions of the report.  All suggestions are given a grade that reflects the level or degree of recommendation. Recommendations are just that – recommendations, not demands or rules.

The part that seems to have everyone outraged is this:

The current versions of health care reform being proposed and debated are really starting to make me wonder. We started off with “making the system better”, “outcomes”, “efficacy”, and “coverage for all”. Now we’re talking about something that is becoming increasingly far-removed from that. And it’s getting worse.

We’re now being told – in the latest iteration of legislation - that there will only be coverage for part of the population (current estimate: 93%). We’re being told that tort reform has to be a significant factor in health care reform – yet in states in which it has occurred, there have been no savings to the patient. We’re being told that the patient will be forced to buy health insurance – in a system that has not inherently changed. It’s like taking your beat-up 1972 Ford Pinto into the shop for a quick coat of spray paint, thinking that might get you a few extra years of driving – but never looking at the oil leak or the old tires. Or the product recall.

The debate now is about protecting the status quo – and has become misguided to say the least, and unethical to say the most. But fortunately, it should now become readily apparent that there is but one solution to health care reform debate.

It’s name? Legislative reform.