A Rant on POPTs | Modern Manual Therapy Blog

A Rant on POPTs

For the love of money is the root of all kinds of evil. And some people, craving money, have wandered from the true faith and pierced themselves with many sorrows-- 1 Timothy 6:10 (as supplied by my colleague Eric Jorde (@EricJorde_dpt))

To describe myself as passionate about the things I care about and value would be accurate. If asked, some of my colleagues, (@EricJorde_DPT, @sowerskristen, and @ARedden_SPT) might say that my passion sometimes manifests itself in the form of declarative statements and the occasional f-bomb. I would be lying if I said that it has never gotten me into trouble. I don't necessarily wake up like a hot bowl full of passion (or is that beard-full?) like Jeff Moore (@jeffmooredpt) does in his daily #PTonICE periscope broadcasts, but it's there on a regular basis. This is one of those times. 

In July of 2015, I returned to Richmond, VA after two years in Tennessee. I was especially happy to be able to return to the private practice I had worked at before having to moving away. However, within the first few weeks of being back, I knew something was different. 

The clinic is owned by a physical therapist and his wife (also a PT), who have been in Richmond for almost thirty years and have had the private practice now for over ten years. They have built a great reputation in the community and have very good relationships with a number of physicians over the years, some of them even becoming personal friends. The owner's leadership philosophy reminds me very much of Southwest Airlines as highlighted by Simon Sinek in Start With Why--> 'put your employees first and they will take great care of the customers.' After some previous frustrating managerial/ownership experiences, it was a welcome return. 

Two years ago, our largest referral source had been a orthopedic spine surgeon from one of the main ortho groups in town, which incidentally, just bought the other two ortho practices in town, giving them an essential monopoly. What was unique about this particular physician, is that he was first a physical therapist before going back to med school. He and the clinic owner have been good friends since they were both in school together in Baltimore back in the 1980's. The ortho's wife, who also happens to be a physical therapist, actually works part-time for us, handling orthotic fabrication and spending time at a local gymnastics gym performing screenings.

What I used to respect about this physician was that while most of the other orthos, especially in his practice, worked hard to keep referrals in-house, his attitude was "no one is going to tell me where to refer my patients." He was one of the few orthopods in town that "got it." Well, that ship evidently, has sailed. The number of referrals we now receive has substantially dwindled from several per week to just a handful over the past seven months. What supposedly is happening, is that the physicians in this practice are given regular breakdowns of how much money each is bringing in to the practice in the form of surgeries, in-house PT referrals, etc. I imagine this simply adds fuel to an already ultra-competitive fire. As the practice has expanded (also having purchased another ortho practice in Northern VA), I imagine the pressure to keep referrals in-house as an added revenue generator has substantially increased. Not to mention, there are home additions and private schools to finance. The reality is, physicians in this type of practice, whether purposefully or not, are likely making clinical decisions based on what is best for THEM financially, not what truly is in the best interest of the patient. 

This phenomenon was highlighted in 2009 and 2011 articles in The Washington Post by Shankar Vedantam and Rob Stein, respectively, looking at the internal referral practices of Urologists. Here are the links to those articles but I've included a few of the highlights below:



 In August 2005, doctors at Urological Associates, a medical practice on the Iowa-Illinois border, ordered nine CT scans for patients covered by Wellmark Blue Cross and Blue Shield insurance. In September that year, they ordered eight. But then the numbers rose steeply. The urologists ordered 35 scans in October, 41 in November and 55 in December. Within seven months, they were ordering scans at a rate that had climbed more than 700 percent.
The increase came in the months after the urologists bought their own CT scanner, according to documents obtained by The Washington Post. Instead of referring patients to radiologists, the doctors started conducting their own imaging -- and drawing insurance reimbursements for each of those patients. 
"I think it's one of the biggest scandals in America today," said Peter D. Grimm, head of the Prostate Cancer Treatment Center in Seattle, WA. "Do you want your dad going to somebody who has a highly incentivized reason to give him one particular treatment that is not necessarily in his best interest?" 
Critics charge that they are a disturbing development in an alarming trend: doctors in many specialties referring patients to facilities in which they have a financial interest, possibly leading to unneeded and sometimes dangerous procedures and adding to the nation's bloated medical bill.
"We need to figure out what's best for patients, not the bank accounts of  (doctors)"-- Rep Pete Stark (D-Calif)

Despite the reduction in direct referrals, patients who have been previously seen by us regularly request to come back. We still occasionally see some patients who have "failed" the in-house POPTs therapy. and we regularly receive feedback from them regarding the stark contrast between the two entities. Probably because we utilize such complex skills as "listening" to our patients and "taking the time" to build a relationship. 

In full disclosure, my first job out of PT school was for one of these POPTs. I was naive and foolish; kind of like when you got that butterfly tramp-stamp on that crazy night in Vegas. At least I was able to get a inside look on how the sausage is made. Within a few months, however, I quickly realized that while I was quite green, the other therapists who had several years of experience, were simply just repeating one year multiple times. I saw very little motivation for skills and knowledge improvement. Continued education certainly wasn't encouraged by any of the PT or medical management staff. Unless you had your own internal drive, why bother trying to better yourself when there's a steady stream of patients just waiting around the corner? 

This is the culture that I witnessed. Sure, the physicians try to sell patients on the convenience of care by going right across the hall. Plus, they can maintain easier communication by being in such close proximity. (Because it's so hard to pick up a phone or send a text these days). But really, that's just lip-service that sounds good to the ears and in a magazine article. What the doctors care about (most, not all), is money in their pockets. PT is a cash machine for them and it's sold under the guise of quality patient care. I know we've seen the debates over the term "quality" on the Twitter-sphere, but at the end of the day.we know quality when we see it. And POPTs PT ain't it. 

Always bet on the horse called 'self-interest'--  Glenn Ruscoe @GlennRuscoe

Which brings us back full circle. This is partly a discussion about friendship and business. While I've always enjoyed Mafia-themed entertainment like The Godfather, Goodfellas, and the Sopranos, I never understood the "it's not personal, it's just business" line (like that helped the guy who just got whacked feel better about it). But this IS personal. It affects the business of people who I value who I chose to work for and who chose me to work for them. They do things the right way. While clinics all around us are trying to increase their bottom line with increased volume, reduced patient treatment times, and the bulk of treatment delivered by PTAs or unlicensed personnel, we have maintained a certain standard to deliver the highest possible quality of care. And that standard is being threatened by one of their long-time friends, no less. Money, it seems, is strong enough to break the ties that bind. But perhaps it's none of my business. After all, I'm just an employee. Well, I don't see it that way. Because what we're facing here in Richmond, VA is simply a microcosm of what's happening around the country. In fact, many of you might be experiencing similar circumstances. 

"Leave the gun. Take the cannoli"

Before you get the wrong idea, I don't want you to think that this particular physician should be referring patients to us based solely on a friendship (although marketing is all about creating relationships, right?). This particular physician, and many others alike, have repeatedly acknowledged how good we were, especially compared to their own PT practices. They send us their "difficult" cases or those that have "failed" their own PT. Despite all that, it has still not significantly curbed their referral habits. The real danger is for the general public, as I mentioned above but is worth stating again is that decisions made by physicians for their patients are not being made on the basis of what may be best for the PATIENT, but rather, what is in the best financial interest of the physician! 

And please, hold off on all the rhetoric that I already read daily on Twitter with regards to hard work and innovation, and providing value, etc. I get it. We're on it. We've got plans and we'll be fine. It's the bigger picture that I'm looking at. (It's actually about what's best for the customer (shout-out Jerry Durham @Jerry_DurhamPT) )

So, I'll conclude with this: If you're a PT who happens to be reading this and you work for one of these POPTs (and I know some of you are because we've chatted on Twitter), here's my question, WHY? If it's a stepping stone to something better--great. If you've been there for a short while and are taking advantage of whatever learning opportunities are offered, few as they likely are--fine. But if not, I challenge you with this. Do you feel you're helping your profession? And maybe an even bigger question-- are you part of something that is truly helping your patients? 

Thanks for reading.


(feel free to send all mean tweets to @EricJorde_DPT)

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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