As a physical therapist, what is the first thing that pops into your mind when you hear the word “maintenance?” What connotation does the word carry? Are you excited by it? Do you have a negative response? Do you sense that maintenance is beneath your level of expertise as a professional? How did you feel in 2013 when you read about the Jimmo vs. Sebelius Settlement? What are your thoughts regarding the recent findings by Bove et al. in Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis from a Multicenter Randomized Controlled Trial?
As a young PT, likely influenced by the perception that patients had to show improvement to qualify for ongoing therapy, I use to think of maintenance as something unskilled, best suited for rehab aides and family members of people with low physical ability and little hope of improving. In the outpatient realm, I thought of maintenance as something completely out of the realm of PT. I viewed it as “the fleecing of America,” where other professions, concentrating on passive treatments, created dependency and reaped huge profits from vulnerable individuals. I looked down my nose at those who put clients on a regular schedule of visits with the goal of maintaining their mobility and health. I assumed every person out there (or their families and caregivers) could, should and would, if given the correct tools, independently care for themselves. After all, we have the best tools available to humankind in PT, right? I harbored an attitude of judgment towards the individuals who purchased those services, or worse yet, who sought insurance coverage for those services, considering them to be either gullible or system-abusers or both. (Sheesh, I was opinionated! And not very nice, either…)
As I reflect on this attitude, I wonder, have some of my PT peers felt the same, and if so, where did this viewpoint come from? The value of cost-effectiveness, efficiency, and minimizing health care visits is not in itself a bad thing. None of us wants to abuse the system, and we undoubtedly need to find ways to curb wasteful spending in healthcare. But have we allowed the pendulum to swing so far that we view maintenance as flat out wrong or unethical? Worse yet, have we de-valued what we do to such a degree that we would consider resources spent on physical therapy to be wasteful?
The APTA allows room for maintenance. The preamble of the Criteria for Standards of Practice for Physical Therapy states, “The physical therapy profession’s commitment to society is to promote optimal health and functioning in individuals by pursuing excellence in practice.” The standards go on to specify, “The physical therapy intervention may be provided in an episode of care, or in a single visit/encounter such as for a wellness and prevention visit/encounter or a specialty consultation or for a follow-up visit/encounter after episodes of care, or may be provided intermittently over longer periods of time in cases of managing chronic conditions…The physical therapist concludes an episode of care when the anticipated goals or expected outcomes for the patient/client have been achieved, when the patient/client is unable to continue to progress toward goals, or when the physical therapist determines that the patient/client will no longer benefit from physical therapy.”
My question: Can people with chronic pain benefit from excellence in practice of physical therapy provided in a maintenance-type model? Are the words excellence and maintenance incompatible?
Over time, I have found myself softening that youthful arrogance and replacing it with more openness. While my stomach still churns a bit when I hear of someone with chronic pain attending visits three times per week for the past nine years, I now understand the human need for connection better, and I realize that patient is having a need fulfilled through that interaction. In addition, those providers may not be as sinister as I thought—they may simply be coming from a paradigm and training that places a very high value on maintenance services.
Clinical and life experience, as well as ongoing education, has fostered empathy, and I now see chronic pain for what it is: an experience that is “emergent.” It emerges and develops out of the entirety of one’s circumstances: nociception, genetics, thoughts, beliefs, fears, relationships, culture, history, work-stress, resilience and so on. And I realize that there is a large group of folks out there who lack the safety net of community and/or the personal resilience to maintain their own health. They simply need support from the outside along their journey.
The question then becomes, whose job is it to offer this support, and who should pay for it?
Consider this case: I recently received an order for evaluation and treatment of a patient with non-specific low back pain who is currently battling lung cancer. While not unusual, these words struck me as I looked at her referral: “End date—to be determined by insurer.” My patient is a very active, two-time Ironman triathlete who had an L4-5 discectomy ten years ago. Imaging confirms there are no metastatic lesions in her back. She went fly fishing with her husband this summer, before coming out of remission, and slipped in the river, straining her back. I have seen her for eight visits now, and she has shown improvement, as she eagerly performs all her exercises and applies the other coping tools I have shared with her.
However, over her last two visits, my patient’s back pain took a turn for the worse. This is no surprise to me, as she also had an episode of shortness of breath, which was ultimately diagnosed as fluid on her lungs, requiring two painful sessions with her MD, draining the fluid off her lung. I find myself in a bit of a conundrum: my patient is highly adherent to her home program, and it is helpful for her, but symptoms are no longer moving in the right direction. She is hovering in a good days/bad days pattern. She is not alarmed by her back pain, yet it impacts her ability to be as active as she would like to be, and she is getting out less and less. The manual therapy techniques we do in PT provide her with pain relief, though it is temporary. I am sensing a transition in to what I would consider more of a maintenance mode as I walk alongside her during this scary season of her life.
I ponder: Am I the best person to continue treating her at this point? Should we continue to seek insurance coverage for her services? Where I used to feel a great deal of inner turmoil in situations like this, I now feel extremely confident in my answers. Absolutely, I am the person to treat her back pain. We have a strong therapeutic alliance, and I am giving her consistent, accurate information about her back pain. I am in touch with her physician, and she also has a counselor on board. We have waded through the deep waters of pain neuroscience education, including the concept that pain is our most potent protector from threat. My patient understands her overall threat level is high right now, and is not shocked that her back behaves like a barometer of that threat. She desires ongoing treatment during this season of her health, specifically finding the manual therapy helpful. If I were to transition her to someone who does not understand how pain works, other ideas would be planted: trigger points, disc bulges, or any other host of explanations for her symptoms, which could actually raise her threat level (and thereby, her pain) higher.
The consistent delivery of good information, along with skilled hands-on care, to a person in a difficult and somewhat uncertain health situation is, in my opinion, a highly skilled service. In fact, when it comes to the question of coverage, Medicare states, “in the case of maintenance therapy, the skills of a qualified therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.” I would argue, that for the person with complex and/or chronic pain issues, PNE plus exercise and manual therapy are reasonable and necessary, and this type of intervention warrants ongoing coverage. I do, however, recognize that payers won’t likely make this easy for us from a paperwork and/or authorization stand point, and that benefits have their limits. This creates the need for cost-effective opportunities that allow patients to engage in maintenance services when their benefits are exhausted.
Fortunately, for me personally, my patients don’t all follow the barriers put on by their insurers. While the referral may say, “End date: to be determined by insurer,” my patients determine their end date, as I run a direct-pay practice. My patients submit their detailed receipts to their insurers for out-of-network coverage, and many achieve decent success in obtaining at least partial coverage for the services I provide. But I find that many people (and not just people with deep pockets), value high-quality, reasonably-priced care enough to budget the money for it. This allows them to decide how much therapy they will receive, whether it is a one-time consultation for acute low back pain, or a once-a-month “booster session” (man, I love that term better than maintenance!). I see those with high self-efficacy and resilience happily apply my suggestions and have stellar outcomes with one or two visits. And, while there is a little piece of me that hesitates to admit this, for fear of judgment, I do have a small handful of patients who I walk alongside on a low-frequency basis, helping them “maintain” their function, and continually planting seeds for just a little more, if that is within their goals and desires.
Thankfully, we are now beginning to reconcile these questions not through simply reflecting on personal opinions and patient stories (though these stories are important…they are where the rubber meets the road!). But thanks to the hard work of researchers like Bove, Smith, Bise, Fritz, Childs, Brennan, Abbot and Fitzgerald, we have evidence to show that, among patients with knee osteoarthritis, “booster” sessions plus manual therapy and exercise prove to be highly effective, as well as cost-effective: “In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs.”
Only time and additional research will tell, but I have a sneaking suspicion that there is a sub-group of patients with chronic back pain, for example, that would fare similarly well with a model of “booster sessions.” Many patients simply do better with a tether, a safety net, and that consistent message that they will be okay, they are on the right track, and we won’t leave them high and dry. In health care, our rugged individualism does not serve us well. Conversely, we do not want to create unhealthy co-dependent relationships. As with everything, the key is to find the precise dosage (frequency and duration, including that somewhat uncomfortable possibility of a duration of “as needed”) of excellence in practice which will best help the patient to thrive.
Soooo…help me out here, friends. What are your thoughts? Are you comfortable with the idea of maintenance? Does it feel better if you think of it as “booster sessions?” Are you willing to go to bat for your clients who would benefit from it? Can you think of cost-effective alternatives for your patients who would benefit from maintenance once their benefits are exhausted? I’d love to get a discussion rolling on this one, as I have wrestled with it quite a bit in the past few years!