Health Care

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 What has become the accepted standard of care and delivery has become outdated, and in the midst of it, the patient – the driver of all of this – has been forgotten.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.

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?

There seems to be a growing aversion to the medical system in recent times. Why are people so hesitant and apprehensive about accessing medical care for anything other than chronic or life-threatening conditions? I certainly see it regularly when interacting with active people. Why is this so?

I am not sure I have that answer completely - but let me propose a few potential reasons.

Just like any other enterprise, there needs to be a value added benefit to going to a clinician for care. The "customer experience" starts from the moment they contact the office. You're on hold waiting for the next customer service representative. A frustrating start, for sure. Let's say you get lucky - and don't have to wait to schedule an appointment. Is the provider of your choice on your insurance plan? Or will this be an (oftentimes exhorbitant and inflated) out-of-pocket expense? Now I have to balance the potential cost-to-benefit ratio of the experience.

The talk of the town (in Anytown, USA) is "Evidence-Based Medicine". If you're in the health professions, I am sure you've become familiar with the phrase. The same holds for those in health insurance - and clinical research. "The evidence" is driving everything these days.

For the record - I am a true believer in the power of good clinical research. I do think that as clinicians we need to provide care based on true evidence-based medicine. We must hold ourselves to high standards of practice, and we must continue to challenge our thought processes and clinical reasoning skills - as uncomfortable a process as this may be. It involves reflection on our practice patterns and perhaps even challenging our belief systems - about our role in patient care or the methods we advocate.

... and Why The Current Medical Model Fails Everyone.

The medical and insurance worlds both claim that health promotion and "wellness" are the key to cutting health care costs and fostering an overall improvement in the health and well-being of our aging population. Health care practitioners speak of wellness and "empowerment". The insurance industry has a desire to cut the costs associated with long-term illness and has (to some degree) started to reimburse for some very basic elements related to self-care.

Unfortunately, the reality is that much of this is talk ... and as they say, talk is cheap.

"Empower" has become a societal buzz word. The American Heritage dictionary defines this word as "to give power or authority to; authorize, especially by legal or official means". But it also points out the following: