Studies indicate roughly 33% of orthopeadic surgeries are unneccessary and could have been avoided if the patient had been to conservative care (physical therapy). There are no checks and balances on orthopeadic surgeries and the cost of treating musculoskeletal disorders annually is over 20% of the total healthcare spend in the US, more than heart disease and cancer combined. We need conservative care first, not surgeries. Read this study to realize this impact is having. Bone and Joint Initiative USA. The Impact of Musculoskeletal Disorders on Americans: Opportunities for Action, 4th ed. 2018. https://www.boneandjointburden.org/docs/BMUS%20Impact%20of%20MSK%20on%20Americans%20booklet_4th%20Edition%20(2018).pdf.
Yet many patients have high deductibles and high copays and cant’ afford conservative care. And the ones who can are only referrred 10% of the time by the doctors.
I am a huge fan of physical therapy and have been able to utilize it effectively in the treatment of injuries and joint issues (and avoid unnecessary surgeries) for many years. That being said, here are a couple of issues for consideration:
Often insurance will not cover PT until a patient has met their deductible, which removes it as a viable option for many people. (Often they will cover it after surgery, but not before).
PT is not always the best first choice. I have observed patients in severe pain that were delayed, and delayed from getting the surgery they needed because the insurance company required them to jump through all the hoops of PT, etc, before they would schedule them for surgery. In the meantime, the patient is in unbearable pain, and forced to take strong medications, often opiods, just to survive until they can be surgically treated. Unfortunately this exact situation may lead to opiod addiction for vulnerable individuals.
Conclusion: PT is a tremendous tool, and should be more widely covered than it currently is, but… doctors should be empowered to make the best decision for each individual patient, whether that is moving them quickly toward surgery, or, encouraging them toward PT, general exercise, good nutrition and other simpler solutions.
Imagine breaking your femur in two and the bone is stabbing through your leg but you get to the hospital and they say, sorry, by law there’s nothing we can do until you complete some mandatory physical therapy. Leave medical judgements to doctors, not the government.
it’s evidently not about broken bones. it’s about the many cases where the doctor does not even consider physical therapy, but surgery and nothing else.
and even before physical therapy, there needs to be prevention.
Tai Qi / Yoga / Feldenkrais / Controlled Articular Rotations type of exercise keeps the joints and muscles healthy and prevents degeneration (especially of cartilage), offers better protection in case of accidents, gives better posture, less pain, more strength, more independence into high age…
Adapted workplaces (standing and sitting desks, ergonomic chairs…), and regular - daily - mobility exercise needs to become standard self care like cleaning teeth daily.
and it needs to be taught everywhere - in schools, in ads, as common break in the workplace, like many asian countries do already.
Part of the health care problem is we tell doctors what they can and cant do. Maybe after 12 years of training and a few more in experience we should let them do their job.
Although this sounds like a common sense idea, I do not think that it is suitable in the US system. I say this as a Healthcare worker myself (Director of Clinical Operations), having worked in the US and EU (France where the healthcare system and the medical outcomes are by far better than that of the US. But before throwing “communist system” comments let me just say that contrary to the propaganda, healthcare there is neither free, nor paid for by the government, nor excluding private insurance or private hospitals, it is just a much much smarter system). In this system, I strongly disagree with any kind of mandatory multi-step process because it is cumbersome to navigate for both the patient and the MD, it forces at times harmful inappropriate steps, it also gives the insurance more opportunities to deny coverage and delay much-needed care. Finally, it also deprives the MDs of their ability to decide with their patient what is the best approach considering this very patient’s circumstances. This should be a decision made between a patient and their Doctor without any mandate to do X before Y.
Example of an injury that can be approached by either PT or Surgery: A rotator cuff tear. Although a married, upper-middle-class stay-at-home mother with 2 kids and her parents next door will have no problem going through 25-35 PT sessions over 4-6 months of treatment, how will a lower-middle-class single mother with 2 kids, who counts every single penny and works 2 jobs find the money to pay for Physical Therapy or its copay AND have the time to go to PT? It is unrealistic. The same goes for a father of 4, carpenter, and sole breadwinner.
It simply is unpractical and even deleterious to people’s health to force them into multiple-step processes where regardless of their circumstances and/or their ability to pay for a treatment and/or follow through with the mandated treatment steps, they will be forced to jump through hoops to get to the final resolution of their injury. In this very example, the single mother and the father of 4 will likely say “I cannot afford that, I will do it later” which will lead to further injury, pain medication addiction, multiple injuries, etc. In both of these cases, a minimally invasive surgery would have fixed the rotator cuff immediately allowing the patient to be back to normalcy within 30 days.
the insurance pays physical therapy, of course. at least in sensible places that put health over private profits.
and if this single mother or overworked father can’t carve out three hours per week for physical therapy - how are they supposed to manage surgery, while being completely out of order for several weeks?
here, too: insurance needs to pay, not only medical costs, but the costs for income missed, too.
and, finally: if people need to work several jobs, or more than 40 hours per week, there’s something very wrong with this situation and this needs to get addressed first. it is well known that chronic stress and lack of sleep generate numerous health problems - prevent them at the root!
I totally agree with the concept of keeping greed in check, but not at the expense of patients, and the problem is the reality check here. A wonderful idea is always limited by its feasibility:
Most offices close at 5pm then people commute
AND
Most PT centers close at 5-6 pm and are closed on weekends,
“How come you cannot carve 1 hour twice a week for 6 months? There is something wrong” will certainly make people feel like inadequate losers but won’t change the realities of their lives. 28% of the population in the US lives under the poverty level and 44% struggle to pay their bills so making this multi-step mandatory, will only delay their care because almost half of the country won’t be able to make it to the PT and/or afford the copay for 6 months which will be around &1500.
From personal experience, I ripped both rotator cuff and my biceps tendon; after surgery, I was able to use my arm within 48h.
I agree that patients should have the possibinity to choose surgery directly if else it gets very complicated for them; and that inferiour care is better than no care, at all.
But, in the meantime, all these problems you mention need to be addressed.
Making physical therapy opening hours longer is not hard; as my dentists manage 24/7…
modifying insurances so low level / conservative therapies and prevention (like going to the gym) gets favoured and paid, needs some political support, but is feasible.
the rest needs majour changes in attitudes as well as laws… but every step into the right direction us helpful and should be done.