SI Dysfunction: A Few Easy Diagnostic Tips

For those clinicians that go round and round with how to assess the SI joint, I thought I'd point out a few relationships I came across during my doctoral case study literature review.  My intent here is not to write a literature review, but just plant a few seeds for you to use next time you assess a patient with suspected SI pain.

1. Don't overlook manual muscle test data!  It can tell you a lot more than if a muscle is weak.  Specifically, hip abduction and the L5 myotomal test. You will very often find the side of the up-slip and rotation will have ipsilateral abductor weakness and ipsilateral L5 myotomal weakness.    Take special notice if the weakness is not bilateral.  Take extra notice if you have unilateral weakness in these areas in a fit individual.  After correcting the SI dysfunction, if your treatment is successful, these two tests will often improve immediately upon retesting the same day.
2. Long Sit Test: don't use the traditional ideas discussed in Magee to determine the effectiveness of this test (the studies show it is a poor test based on their definitions).   But when used as a broader "red flag" test, I feel it is an excellent tool.  If the malleoli change in ANY WAY during the supine to sit, don't over think it, just consider the test positive and start seriously suspecting an SI problem.  If the leg length is the same difference in supine and long sit, you have a true difference and start digging around for a heel lift (but I've found this is the minority of people).
3. Last test to consider.  The "Shotgun Test" for adduction strength in a hook-lye position.  If this test is painful or weak (or both) you probably have an SI problem.  Also will need to clear L5-S1 if this is weak.  

These tests are ones that are performed as part of most evaluations, and the Shotgun Test is used as a part of most SI treatments.  But start putting them into your mental assessment calculator, using them as possible SI tells, and you might find your success rate when treating these difficult patients goes up a notch or two.  All questions regarding this topic are welcomed.  

Cost of PT Education

Does anyone think the cost of a PT degree is getting out of control?  I'll admit, the cost of all college education is getting ridiculous, but let's take a look at the cost of PT education.  With the average private graduate program pushing $50K per year and the public schools not far behind, when is the bubble going to be reached where the truly smart individuals start to say, "why would I pay that much to make $65K per year?"   It is a significant problem.  The schools continue to pump out DPT's with the ideals that they are the next greatest thing to the field, and are demanding higher starting salaries as a result.  Clinic owners are short of staff and scared not to meet their demands, offering higher starting salaries, while only modestly increasing their most senior therapists' salaries.  (Which by they way, are the real casualties in this argument.  The new grads are now making close to the experienced therapists.  Is that fair?)
What seems odd is that when I turn away a new grad after stating "this is the best I can offer you," there tends to be another clinic owner out there ready to meet their outrageous demands the following day.  The perfect example was a person I interviewed last year for a vestibular position.  She wanted in excess of $85k per year based on her experience.  But given that she could only see one patient per hour, my math showed she would be making 55% of the gross on her maximum that she could bill (if she were 100% booked), guaranteed regardless of her patient volume.  That didn't seem right and I told her this, stating that a bonus structure could be arranged once her program generated new business outside her own 40 hour a week caseload.  She of course balked, and went to work for a local hospital system.  My question is, what are the bean counters at the hospital doing to create an hourly wage for these people?  At some point, do you not have to figure out how much a person generates vs. what their salary requirements are to make a logical decision?  I sometimes feel I am in the minority when it comes to these business decisions in the PT profession.  And if the majority of clinics are not doing this type of calculus, how are they staying in business?
I fear our profession is in jeopardy of two things.  First, pricing itself out of the market regarding fiscally responsible job offers.  Second, eventually limiting the number of quality applicants in the work field by offering a poor return on investment regarding the cost of their education.  Sure, right now while the overall job market is bleak, there are plenty of people applying to PT programs, but what happens when things turn around?  You don't have to be a genius to figure out a $150-200K loan for  a $65K/ year job is a bad deal.  Will we have bright people coming into the profession down the road if they are smart enough to figure this financing nightmare out?  Can the PT schools figure out how to get the job done of educating our students in a more cost effective manner?  The question needs to be examined.  We certainly can't just keep cranking up the costs year after year and expect things to continue to work out (see the US debt scenario as an example).
Given that reimbursement is only going to continue to decrease in the coming years, the leeway clinics are going to have to hire new grads at these higher rates is only going to shrink.  Would you want to be a new PT in the current market?  How about five years from now?  When are salaries going to have to drop to match the reimbursement of the day?
Unfortunately, I doubt schools are going to get cheaper, much less do I think insurance companies are going to pay us more for our services in the coming years.  It's a pretty picture isn't it!?   But this is a discussion that needs to be addressed.  Why it rarely seems to come up is puzzling to me.  Nothing would make me happier than to have someone convince me things are going in a different direction and that I have it all wrong.  I'll be listening.

ACO's Competing for PPO Business

Historically, ACO (Accountable Care Organization) groups have serviced HMO contracts.  Because of this fact, they have flown under the radar of most PT and MD offices that provide services to PPO patients.  But will that always be the case?  It has yet to be determined, but it is one of the key ideas that will need to be ironed out if the ACO movement is going to have an impact nationally.

• If you were running an ACO, why wouldn't you want PPO business?  The primary reason would center around the capitated pay structure most ACO's were built around and how that impacts how it's physicians are paid.  PPO's with fee-for-service structure don't fit this model easily.
• However, attracting PPO business is important since increasing numbers of national employers are getting away from individual, local HMO products and purchasing national PPO plans for their employees.  This trend has shifted overall insurance coverage away from HMO plans.  
• PPO's are also attractive because they are not regulated by groups like The California Department of Managed Health Care (DMHC), which place significant regulations on ACO business.  PPO service is resultantly much cheaper and easier to provide to patients. 

No one has yet come up with the perfect fix for this HMO/ PPO problem, but given that both providers (ACO groups) and insurers are motivated to find out a solution via the Obama-care initiatives that are coming, it will eventually get worked out.  If a cost effective model can be created (call it whatever you want), the employers who have been getting killed with increasing annual premiums will jump on board quickly if it helps them save money on their bottom line.  And when that happens, the ACO issue might become very real to the general public.

Looking forward, here's where it gets a little scary.  What if you are an independent provider in an area where an ACO aligns itself with all the providers (Medicare, PPO, HMO)?  What if the ACO includes the largest hospital system in your neighborhood?  Can you still compete?  Where are your patients going to come from?  Will your reimbursement rates be anywhere close to theirs?  

For those of you thinking, "Isn't it illegal for hospitals to employ physicians in California?"  Well, there is a business structure called "the foundation model" that makes it all work legally.  The physicians become part of the hospital's foundation, creating an obvious allegiance, but are not considered simple "employees" of the hospital.  The result is you have a group of MD's that become part of that hospital system.  

• The sales pitch from the ACO to the consumer will be that they will be able to provide the best care around because of their signifiant integration of great doctors, the hospital, ancillary services, and great electronic communication.  Patients won't have to fill out their information repeatedly for each doctor they see, since all their information will be shared amongst each of their providers.  This will increase efficiency on both ends and also cut down on repeat tests due to improved communication.  There is a lot of truth to all this.  This is the utopic vision that is driving the EMR revolution.  
• The ACO pitch to the insurer will be that since they can control costs better, they should be able to offer lower rates to their customers.  Initially that may be the case, but eventually the more probable truth of the matter will be that you will have an entity that cannot be overlooked at the negotiating table.  The ACO will have significant leverage to negotiate contracts with PPO providers, which will only make the playing field that much more unbalanced for the independent providers.  Sure there are federal anti-trust laws that help protect against these practices, but they are already in place, and look how fair things are currently!?  The combination of hospital reimbursement rates for Medicare patients and leveraged increases in PPO reimbursement, due to the percentage of the population they are serving, makes sense for the ACO.  But it could very well spell difficult times for those outside the ACO umbrella.  
• Would you want to compete against this group?  I hope for your sake you never will, but I wouldn't bet on it.  Keep an eye on this topic as 2012 unfolds.