Hey there, Tony. Thanks for joining me today on the Pain Science Education podcast.

My pleasure.

I’m looking forward to talking to you. You have a wealth of experience in pain research, physical therapy, um, back pain, acute pain, chronic pain. So I’m really looking to lean in and I know our audience is looking to learn, um, from you. I think most people are probably familiar with your, your most recent work, which is the target trial. It was a large pragmatic randomized controlled trial in in different sites. I don’t want to focus too much on that today, but I think we can give people some background so we can talk about the broader topic, maybe the more important topics we’re going to talk about today. But tell us what the aim of the target trial was.

Yeah, we answered a call from the Patient-Centered Outcomes Research Institute, or PCORI, for a study that was pragmatic on real life. And it was designed to uh, test interventions that would prevent the transition of acute low back pain to chronic low back pain. Um, so it was right up our alley. We were very interested in it. Um, it was a lot of money. I’ve never, I had never, um, overseen a budget that large for a trial. Uh, we ended up initially recruiting, uh, uh, five sites that ended up being, uh, one site was a failed site. So we had four sites, and we recruited thousands of patients into this pragmatic trial. And we compared, you know, we set the bar very low. You know, we looked at care in a primary care environment, and that was largely chosen because our stakeholder engagement with insurers told us that in primary care, primary care was a real problem area for managing back pain. A lot of low value care precipitated from primary care and not a lot of evidence-based care precipitated from it. So that’s why we decided to look into that. And we looked at, when we talk about transition to chronic, we wanted to kick off patients we thought were at high risk for chronic. And we were capitalizing on start back tool and looking specifically at that high risk group, which is why we called it the target trial. We targeted that group. And the intervention for that group was this, what we call psychologically informed physical therapy. And we, you know, sort of followed the Start Back original trial by the people in England, but tried to make it work for PCORI and work in the U.S. So we had a usual care group, and then we had a group that we tried to intervene with, with psychologically informed therapy. And just granting aid, the study section liked it, and they funded it, and Of course, you know, as a researcher, that’s when the trouble starts. You have to pull it off and carry it on, you know, but that’s what started it and that’s how we, and we were funded and it took about three and a half, four years to get the trial completed. And we’re still publishing things on it. And the actual data set itself is now free for anybody to go look at. mine, however they want to mine it.

So a patient experiences low back pain, they go into their, let’s say their internist, so to speak their primary care provider and say, Hey, I have back pain. How can you help me? And as you mentioned, there’s a lot of what we call low value care or care. That’s sometimes inappropriate for people with back pain. And you come in with a team and say, well, we’re going to apply this start back tool. And we’re going to screen and see who’s very high risk for that transition from acute pain, which is typically less than three months of chronic pain, which is typically more than three months.

Right.

And for those at a high risk, we’re going to refer them to psychological informed physical therapy.

It’s that that’s in general what we aim to do. So. Remember, it’s a pragmatic trial, so we didn’t, it’s not like we take these people and pull them out of primary care and put them into a lab and investigate. We had to make everything fit into the everyday practice of primary care. So just to take the example you’re talking about, for everybody that came in with back pain, we decided the only way to do the trial was with cluster randomization. So instead of randomizing individual patients, we randomized entire practices. So we identified about 70 practices that we randomized into either what we call the PIPT group or the usual care group. Usual care, what we did was just let them function like they normally function. And then in the intervention group, what we tried to do is identify those patients who are at high risk, using the electronic health record. So patients would come in, we used tablets to administer a patient reported outcome, to administer the start back tool. And then we developed a chronic questionnaire that was based on the NIH definition of chronic. And we defined acute as anybody that wasn’t chronic based on that definition. Then of course, When we follow it up with patients six months later, we use the same tool to see if they transition to chronic.

Right. And I guess maybe we should just give people a quick window into the start back and explain what is it about that tool that helps identify who’s high risk for that transition from acute to chronic pain. I think that would help clinicians especially.

Yeah, it’s a great tool. I still think, you know, it’s been reviewed and it has its ups and downs, I think, you know, but I think it made sense. First of all, it’s easy to administer. And in a pragmatic trial, you had to do this. I have to just digress a minute, you know, when we were trying to talk primary care physicians into the study, the first thing they would say to us is, if you give me something to do that takes me time, I’m not going to do it. So we put all of this information into a tablet that communicated directly with the electronic health record. Now, the start back was just, you know, it was nine questions. For the most part, it’s designed to look at elements that really, you know, are predictive of persistent pain. So elements of depression, elements of catastrophizing, elements, you know, these psychological variables that are not any one would necessarily be predictive of persistent pain. But when they are grouped together a certain way, the data showed that, yeah, they were predictive of persistent pain. Now, so we had a group of people that were not chronic already, based on that definition. fill out the start back tool and they became, and they were of high risk. So they really had a lot of these factors piled on. And we targeted those people and did this. And the intervention itself was an automatic referral to physical therapists that we had previously trained. in this psychologically informed physical therapy approach, similar to how they did it in the British trials.

So these patients show up, you screen them with the start back, they score high on things like fear, pain, catastrophizing, depression, anxiety, pain, bothersomeness, so to speak. So the cluster of these, what we call psychosocial factors, which becomes like this red light almost, this trigger, which I think is really smart that you put the trigger in the EHR. Nowadays, healthcare is so busy. Professionals need little triggers like that. They’re helpful. And then we refer them to a psychologically informed physical therapist. I think it’s probably just mentioning, worth noting how much training those physical therapists may have had in that area.

Yeah, so you have to look at the RFA. We’re trying to follow it. It was very prescriptive. What you need, we were, first of all, the interventions were done with community-based physical therapists. We didn’t, again, bring them to a lab and have something very artificial. Secondly, we used, we had contact hours that matched up well with the continuing education requirements for licensure. And we did it like a continuing education course. But we had people come in from the outside. So Steve George, he’s now at Duke at the time he was at Florida, led a team with Jason Benacek and others, and a clinical psychologist, and they developed coursework. And we went into the areas where, you know, after we cluster randomized, we looked at the areas that had the, you know, that used the physical therapists, where the primary care physicians used these physical therapists, and we infiltrated those areas with training. We didn’t require training, but we sent, physicians sent notes to those therapists saying, you know, they really want them to take this course, and it was free. We offered it for free. So yeah, in a pragmatic sense, I would say, you know, if you had this on a spectrum of, you know, explanatory to highly pragmatic, the intervention was highly pragmatic. We didn’t, you know, we didn’t force the patients to go to PT. We just said, we gave them the referral and encouragement from the physician’s offices. We didn’t force the therapist to do the training. you know, but we did say, if you call it coercion, it’s, you know, a physician asking the therapist to do this, if they, you know, for their referrals, I think is as close as you can come to real life, you know?

Yeah. And how many hours of training did they receive the PT?

I think it was about 10 to 12 hours total. Okay.

I’ve done hundreds of interviews at this point. I think it’s probably a good place to just pause for our listeners and just let them know that. Because you’re familiar with this trial, but this is a really significantly large trial. As you mentioned, when randomized control trials are conducted in kind of more controlled settings. Maybe you have 5,200 patients get whatever, physical therapy, and 5,200 patients get Tylenol, so to speak. And they’re compared like that. But you’re actually going out and you’re training physicians, as well as physical therapists, you call it pragmatic, but in real life settings, essentially.

That’s right. That’s what pragmatic means.

Yeah. Who are not, they’re not used to working in a research capacity, so to speak.

Correct.

Right. Right. Which can, you know, having managed many physical therapists in different clinics across different geographic settings, that can be really challenging.

Absolutely. It’s, it’s a, it’s, it’s very difficult. It’s, I have to be careful how I say this, but it’s, it’s, extremely difficult to get any practitioner to follow evidence-based guidelines. Clearly, there’s enough evidence to support, you know, a psychologically informed approach, especially in these high-risk patients. And as you said earlier, we commonly don’t get the benefit of the results of a start back. You would think that people would welcome it. You would think that people would not only welcome it, but then listen to what’s being reported and then do something, especially something that in the intervention, something that we kind of broke down a lot of barriers to, you know, these, these courses were extremely well received. We published papers that demonstrated people’s confidence, the people who took the course, their confidence in managing people with psychological barriers to recovery, improved tremendously after the coursework, they had tools, they knew They knew ways to kind of coach people through. It was more than just the physical treatment. They were actually combining this biobehavioral kind of approach. We showed they learned that, and we showed that their confidence went up in that. So you would think that this is a perfect, this is a match sort of made. But given my experience, it’s It’s hard to, even if you can get a short-term improvement in care, it’s hard to sustain that. It’s really hard to sustain it. People fall back into their comfort zones. And to be quite honest, there’s no cost to them not doing it. other than they still get paid the same amount of money, they still get the referrals, everything is. In real life, this is why the more you move your studies to real life pragmatic approaches, what you see diminished is the effect size of that intervention when you’re not tightly controlling it. But what you gain from it is generalizability. And that’s what PCORI wanted. They wanted a highly generalizable trial.

Yeah, I think that’s really an important point because, as you know, most of health care is not a highly controlled environment, basically. So we have to look at interventions and say, OK, can this be delivered? As you mentioned, the average, quote unquote, physical therapist or primary care physician, if they can’t engage with this, then this might not be the direction we want to go, or we might have to adjust what we’re doing in some way. Do you want to share with us the outcome of that target trial?

Well, it was a null trial. We did not reduce the transition to chronic. Now, you could say the question that always comes on trials like this is, Is it a problem with the intervention itself, and it just wasn’t robust enough to cause the change? Or is it a problem in implementation? Because in a pragmatic trial, you have to be careful. You can’t do too much. You can’t do too much to control the implementation, because then it becomes less pragmatic. So here’s what we did. in an effort to try to keep the trial pragmatic, but at the same time, do something so that you weren’t just comparing two groups of usual care in the long run, right? So in the experimental group, as I said, the questionnaires were given, the people at high risk were identified. In the experimental group, that automatically turned into what is referred to as a best practice alert. in the primary care setting. And that best practice alert triggered the referral for psychologically informed physical therapy. Now, when we talked to our primary care brethren, we tried to push for an opt-out. In other words, that referral would go to the patient no matter what, unless the physician said no. And the physicians were adamant, there were enough of them opposed to that. They didn’t want that automatically going out to patients. So it had to be confirmed. And about 40% of the times the physician didn’t confirm it. Now, was that because they were against psychologically informed therapy? No, it wasn’t that, they were too busy. You know, and the trial was two years, you know, ongoing. They were busy practices. They had people coming in and coming out. You know, some of them, you know, by the end of the study, weren’t even aware of the target trial. We tried to keep up with things, but it was hard to get them aware. So, you know, right away, we lost 40% of the intervention just because somebody didn’t push a button. You know, in our study, in our write-up of the study, And what we would do differently, the reviewers were telling us, you should have put an opt-out on it. You should have had that referral go automatically out. So that’s one major factor. Now, the second factor was, even when they got the referral, PCORI did not allow us to pay for treatment. So we had to depend on the patient being talked into going to therapy, paying co-pays, the whole nine yards, doing all of that. And so we had some loss from that component. Patients would just say, I’ve been to therapy before, I’m not going again, stuff like that. Or I can’t afford the co-pay. That’s real life. That’s what happens in real life. Again, if I had to do it over again, I probably would have engaged more with the payers. and just get rid of that barrier of the co-pay. I think that would have been a big thing that would have helped a lot. And what we found out later is that’s what a lot of payers are doing now. They’re trying to reduce the barrier to go to non-pharmacological care. And UnitedHealthcare, for example, is underwriting a lot of commercial plans where they’re giving patients cash cards, you know, to cover co-pays, you know, things like that. But, you know, I didn’t, we didn’t know enough, you know, at the time to, you know, it’s 2020 hindsight. So those two factors alone make me think that the intervention itself, I don’t think we can indict the intervention itself. I think we have to really, for the most part, look at the lack of implementation.

I mean, you know, in randomized controlled trials, people obviously receive free treatment and sometimes they’re even incentivized to come to treatment.

Yeah.

And as you mentioned, I think Unite Healthcare, you know, may be onto that where they’re incentivizing people to go to non-pharmacologic care like physical therapy instead of choosing things that are more interventional, invasive, which is interesting. So the physician piece is, is, is interesting being a long time clinician and, you know, having colleagues that are primary care doctors or orthopedic surgeons. So they were, I guess, in some way able to override that trigger that this person needs psychologically informed physical therapy.

Yeah, they just ignored the best practice alert. Now, in the meantime, we looked at practice behavior in the primary care settings. And in spite of being in the middle of an opioid epidemic, we still had over 20% referrals, prescriptions for opioids. being written on a early visit, early either first, you know, within weeks of having an episode, you know, so sometimes the first visit to the primary care physician writing opioid prescriptions. We still had significant numbers of referrals for specialist care in those initial visits. We still had significant numbers of advanced imaging being ordered. All right, and we still had, you know, And we still have a lot of x-rays being ordered, okay? So, you know, you can see, you know, my subsequent work now, psychologically informed therapy, that’s a high bar. How if we just stop getting physicians to order x-rays? Get physicians to stop ordering specialist care. Get physicians to stop, you know, ordering advanced imaging and stop prescribing opioids. Just those, let’s just start there. And what kind of an impact would that have on care? And maybe get them to do one, refer for one non-pharmacological intervention. I don’t care what it is, physical therapy, chiropractic. acupuncture, yoga, I don’t care, massage, I don’t care what it is, just one non-pharmacological treatment and don’t do the, what I would call the stupid things that, you know, it just seems to me like, you know, we, I, you know, and I think about all the work I did with back pain and all the work, all the studies we’ve done and how granular we got with the interventions. It wasn’t just doing physical therapy. It was matching with, you know, treatment based classification and doing, you know, even, even doing some of the biobehavioral things, you know, and then I look at the, the way it’s happening in real life out there. And the emergency room care, which is highly prevalent, the primary care physician care, which is highly prevalent, maybe we just need to set a lower bar and start to work from that, and then maybe get more granular as we go up. But we found in a secondary analysis of the study, which I think was one of the more impactful findings, was the more what we call, you know, there’s adherence to just general guidelines and then there’s non-adherence. And the more non-adherent care there was, that was the only predictor of chronic. the more likely people were to turn chronic at six months. The more non-evidence-based care they got, the more advanced imaging, the more opioids, and it was compounded.

I think it’s worth mentioning just because we have practitioners as well as like the public who listen to this podcast. So when you rattle off things like the patient received an opioid, the patient received an x-ray, the patient received an MRI, The patient received a referral to an orthopedic surgeon, a specialist, as we say, for their acute low back pain. What you’re really saying is that should not be first-line care, and there’s substantial evidence to support that.

Yeah. It’s not only me saying it, the American College of Physicians is saying it. What the American College of Physicians is saying also is that it used to be pharmacological care or you know, non-pharmacological care, you know, and they were weighted equally. And with the opioid epidemic now, and, you know, the most recent American College of Physicians, it’s non-pharmacological first. You know, that’s what, that’s what is, and we were trying to capitalize on that.

It should be non-pharmacologic care first.

Yeah. Yeah. And that’s what the guidelines are saying. Yes.

Because you and I both know.

Yeah. Yeah. Their own physician guidelines are saying that.

It’s interesting because it’s really not about is psychologically informed physical therapy, evidence-based, beneficial, useful, impactful for someone’s physical and mental well-being, let’s say disability, things like that. It’s not even really about that. Really, it’s starting to become What are the real-world challenges that exist in all our various healthcare settings, especially in the US, because we have a very diverse systems, especially depending on what state you’re in. What are the barriers that people or practitioners, as well as patients, what are they faced with to access this type of care, even though we have, quote-unquote, all the guidelines published?

There are significant barriers that I see. And probably to me, the barrier that has to be overcome first is we, when I say we, the collective we who are in the healthcare delivery system have to have the will to really move to value-based care. And it’s very difficult for me to say this, but a lot of money is made on low-value care. Those MRIs, those specialist referrals, they generate a lot of revenue for health systems. You know, we could say let’s eliminate as much as we can low value care, which would be what we’re talking about here. That’s going to hurt the bottom line of a lot of the healthcare institutions, especially when you think about the prevalence of musculoskeletal conditions.

Yeah, I mean, if if the things you and I are talking about, we could flip a switch on it today and tomorrow, those things are not happening, so to speak. You’re probably talking about a billion dollar change in our health care system, which is which is, you know, when you read the literature, that’s what everyone wants, so to speak. But if you’re the I don’t know, health care administrator, accountant, looking at the bottom line of an organization’s, and it’s always interesting to me because, you know, hospitals are quote unquote, not-for-profit organizations, but yeah, profit is what’s driving a vast majority of what happens, I think, in pain care in the United States of America.

Yeah. Yeah. And what you’re talking about, you know, in that as far reaching, implications if we start talking about you really changing care. I mean, one of the things we know right now is that the cost drivers for an episode of musculoskeletal care are largely dependent on where the person enters the portal of entry of the person. And we’ve had plenty of observational studies that have shown this to a point where Even the payers are realizing this now. And sometimes some of those studies are coming from payers. You know, the portal of entry is, you know, if the portal of entry is an emergency room or a primary care physician, you know, you can, and you compare that when the portal of entry is a non-pharmacological provider, the cost of care is generally a lot less in the latter. We know that. So you’d say to yourself, wow, if we’re driving ourselves to more efficient and cost-effective care, why don’t we just flip the switch? Well, we don’t flip the switch because the people that are driving the care are the people making money on low value care. And I’m not against making money. I’m not against it at all. But when you are looking at the cost of musculoskeletal care right now, which now rivals taking care of people with cancer, and sometimes exceeds it in certain payer groups. Back paying can’t cost you that much money. It just can’t. If you go to the real payers, which are the government and the employers, they have to be looking at this saying, wait a minute, why does back pain cost me this much money? You know, and then if you look, if they take it a step further and say, well, wait a minute, what are we spending this money on? Sooner or later, they’re going to discover they’re spending the money, a lot of the money on low value care. So if you’re a payer, what makes you want to pay for low value care? You know, and I’m wondering if the employers themselves are just lulled into, well, this is what it costs me, and so I’m just gonna budget it, and that’s the way it is. Or if they really can be empowered to change, because I think the real payers, if they were brought to the table and saw this with the data that was right there in front of them, I think they would have the power to change what’s going on.

I mean, some of this I think is, you know, from a societal perspective, I think we’re very lured into new high tech, you know, and some and you see that in the marketing of different types of interventions for pain. you know, a new drug or a new intervention, a high-tech way to deliver an injection in the spine, which is really not that difficult actually. So, you know, you hear this, this, you know, obviously this is marketing language that’s positioned to patients with pain. So it’s almost like how to, so, you know, on a systemic level, you know, these are the questions we’re contemplating today. How do we start to say, okay, we have this body of research. We can keep going this direction and explore these interventions. We know generally they work well if people have the opportunity to access them early and to engage with them for a significant amount of time with a licensed professional.

Right.

But how, I guess, what are the best practices that health care organizations can do to start to implement things like that into, as you said, maybe it’s an employer, maybe it’s a large insurance company that might be listening?

Yeah, I think, you know, I’m trying to be somewhat optimistic. I think we cannot continue to go this path. Let’s assume that we both agree that we just cannot afford to keep going down this path. So how do we bend the curve? How do we take it to a different path? I think, first of all, we have to acknowledge the fact that we just can’t cut the healthcare systems off cold turkey, if they’re depending on this money, they’re already financially strapped. You know, however, maybe what we can do is better pay the evidence-based care and don’t pay the not evidence-based care as well. I mean, MRIs cost a lot of money. One MRI would pay for a lot of therapy. You know, and, you know, at the same time, you know, what insurance companies are doing is they’re squeezing every part of the turnip, as opposed to, you know, squeezing where they should be squeezing, you know. They don’t wanna ration care. You know, they don’t wanna be the ones that say, you can’t have your MRI, you know, when your doctor ordered it. You know, they know that won’t work. But I do think that there are models across the country that are discovering ways to go about managing, employers are anyway, managing their employees and their families better. And what it takes is bringing that employer to the table with the provider, and developing these, just having that conversation, having that dialogue. By no means has anybody solved this problem, but I think they’ve made headway. There’s a nice example in Oregon for this, where Intel and Providence Health, published in the Harvard Business Review, had a really nice liaison And as far as I know, that has continued. They put together stakeholders that represent the employer, represent the provider, and then they have an oversight group that identifies the pathways that need to be taken. They have ways to measure whether those pathways are taken or not. And then they have benchmarks that have to be achieved. So for every person with back pain, how many times did they have the right portal of entry, how many times did they have the wrong portal of entry? Everybody agrees on benchmarks. They’ve bent the curve. They’re doing what they need to do to reduce their costs. I’m not sure what they’re doing about the bottom line for the provider. But according to the Harvard Business Review, this has been sustainable. That’s an example of bringing the real payer to the table, as a stakeholder. And I think they have more power in this conversation than they realize. I mean, the government’s the same, the other major payer. And we know the government, when they want to, can really influence good care. I mean, I think the total joint bundle was a fantastic example of that. I think, I know we, were able to turn on a dime, you know, how we manage people with total joints in our system, very large system in Western Pennsylvania. And, you know, when we were told we had a bundle, the first thing we did was get together and say, you know, what’s the best way to get these people through the system? Not how can we milk the system for as much as we can, you know? And we started asking simple questions, you know, do we really need to be sending people to a SNF? or can we get them better ready for surgery and get them out in a reasonable timeframe from acute care? Those kinds of questions. How do we use rehab the best? Does everybody need home care? Or should we be getting people that aren’t homebound and move them into outpatient care where we can do a lot more with them? We answered some real tough questions. Do we do nerve blocks or not do nerve blocks? You know, nerve blocks cost a lot of money. And are they really that beneficial? We had five different hospitals. We had five different protocols for managing prevention of DDT that range from baby aspirin to Lovenax. you know, what, what’s, you know, got a $1,500 injection versus a baby aspirin, you know, how do, what’s, what, what’s, what does the evidence say and how do we implement this across the board? You know, these are, this is what you’ll, this is how people will start thinking when you bring the payer to the table and the payer comes to the table and says, I’m giving you a bundle and you’ve got to, you’ve got to manage that bundle. You know, that’s a different approach than a fee for service approach.

Yeah, I mean, that’s a financial driver in some way. Someone’s made a change the way that we’re all financially incentivized, so to speak. So in some way you have to change. These are oftentimes complex problems embedded in systems that require new processes to be put in place that I think manage, obviously it manages the patient flow. It also manages the provider behavior. Do you think we’ll see things like clinical decision support software playing a greater role in really helping providers, especially primary care providers. We know they don’t receive a lot of education in musculoskeletal care. So would they benefit from something like that? Are they open to using something like that even?

They would certainly be open to it if there was a financial incentive. We know that. Or a financial disincentive not to do it. So, I mean, I don’t think there’s any doubt they’d be open to it. I think there are a number of opportunities. Embedding non-pharmacological providers is one. If you can embed a physician assistant, why not enhance these people that they’ve generally referred to as APPs, advanced practice providers? I mean, that’s a term I don’t think that should be you know, exclusive to nursing and physician assistants. We can put any professional in there. At Intermountain Health, they showed the benefit of embedding nurse practitioners who are trained in behavioral health. And they showed that that comes back in spades in terms of savings and better management of people. So I think the models are there. We just have to, for the most part, I think what we have to start doing is, you know, just for the most part, expanding the physician’s scope on what’s possible there. And don’t, you know, don’t fall for primary care physicians who tell you that they can’t stand back pain and if it were up to them, they wouldn’t see it. Back pain, they’re a volume-based operation and back pain’s a big volume. I credit my longstanding colleague and friend, Dick Earhart, the late Dick Earhart, who used to say, I’ve been around, he’s been in this game a long time, and back pain is like the bone in the yard of two dogs. Neither one want until the other one does. And that’s what back pain was like. Nobody wanted to see back pain until we wanted to see it. We wanted it directly sent to PT and the primary care physicians start screaming bloody murder. All right, fine, if you can’t beat them, join them. I mean, we should be a part of the practice. I think of a physical therapist as a part of a primary care practice makes perfect logical sense. And, you know, when we did this at the VA, we didn’t do it with physical therapy, we made chiropractors part of primary care. The primary care physicians spring bloody murder at first, but then guess what happened? Wait times went down, patient satisfaction went up, the veterans were really happy, and the primary care physicians got to spend more time on their complicated cases. and not trying to manage back pain, which they didn’t know the first thing of how to do it. And there’s a system that really, volume doesn’t matter. But still there was the professional sort of jealousy there. These are not easy problems. By no means are they easy, but sometimes it just takes a crisis to handle it. In the case of the VA, the crisis was people were all upset about wait times. and with the prevalence of low back pain and huge wait times for these veterans, you can imagine how that got amplified. It’s clear hiring more primary care physicians wasn’t going to be the answer. When the notion of putting chiropractors there was brought to them, there wasn’t a hierarchy at the VA that was a problem. It was the primary care physicians themselves who were But now, I don’t think they could live without it right now.

What’s your advice to physical therapists? Because there’s a lot of advocacy, I think, wrapped up in this. Because we’re really talking about changing payer perspectives, potentially changing healthcare policy, I think, maybe even on a government level. Things like Medicare, that could change, so to speak. What do we have to do as, not just physical therapists, other health professionals to, as you mentioned, try to shift this toward a more biobehavioral intervention for people?

There’s a lot of things I think we can do. First and foremost, if we don’t find a way to not just better pay our therapists that are in the trenches, but find a way to better pay physical therapy, period. I think we need to find that sweet spot where the payment we’re getting is concomitant with the value we’re adding. And in turn, not just that, but create environments where we can actually practice the way we need to practice. We are stuck in this volume-based approach, and now it’s gotten to the point where When I came out of school, we could pretty much spend the time we needed with patients and still make a living. As time has gone on, that volume-driven approach has kind of infringed on that. You know, when I was practicing a lot, I could still practice in an evidence-based way and still make a living. I think we’ve gotten to a point now where it’s difficult to do that. The volume drive has gotten so much, so intense. that it’s now almost impossible, especially when you couple it with paperwork, to deliver the kind of care that we were trained to deliver and make a living.

And- Because the vicious cycle there is physical therapy is reimbursed very poorly. Yes. We’re not getting paid a lot, because we’re not getting paid a lot of money to pay our overhead, to pay our salaries. We have to increase the amount of patients we see per hour. When you’re seeing a lot of patients per hour, typically you’re shortening the treatment session, then it becomes very difficult to deliver best evidence-based practice or evidence-informed care because when we’re talking about especially chronic pain, acute pain may be a little bit different, but especially chronic pain, you need time to deliver psychologically informed care with patients.

You’re exactly right, and I don’t have the answer. However, If we are reimbursed in a more value-based manner, first of all, understand what I’m saying, because you have to be careful what you’re asking for.

Right. So then it’s not just we’re going to give the PTs more money. It’s the PTs have to demonstrate that they have additional skills that requires that they have more time now to be with the patient. You’re not just going to give them more, quote unquote, exercise, so to speak.

And you have to be accountable to that care.

Yeah. Not only do you have to deliver the care that’s evidence-based, you have to stop delivering the care that’s not because, you know, the analog, we talked about primary care physicians and the analog to their MRIs and everything else is our passive care. passive therapies that we can’t get away from using. Now, I know. Yeah.

And I’ve also, you know, I saw you mentioned in your paper where you talked about, um, you know, this like skill drift that happens with, with professionals. They come in, they learn a psychologically informed type of environment. They use it with certain patients and not others. And then they maybe, or they maybe decide to use it like at session five when the patient’s not doing so well, instead of you starting it at session one, you have to literally change your entire practice essentially. With every single person that walks in the door.

And at the very least be accountable to those treatments as you’re saying. But also find a way to be accountable to more than just this one outcome with this patient. You know, I would love to see kind of you know, approaches by payers. And if you got to the, if you got to the real payers, like again, the employees, employers and, and the government, and you, you had as a goal, you know, you know, again, your treatment is whatever treatment entity you’re a part of. If you use us, you will have less MRIs, you’ll have less need for specialist referrals, those kind of things. Find a way to kind of share savings. In other words, you know, my intervention is, you know, maybe it has to be done with, you know, in a multidisciplinary way. But if you use us and our approach, you will spend less. And that spending less should be, and this is why I think people refer to and pay for performance or shared savings, those kinds of approaches, which are hard to come by out there. But some of those, that’s where I think we need to be spending time and energy in a research mode. How can we demonstrate that these kinds of things, these kinds of approaches can pay off in the long run? and pay off, you know, with more efficient care. I, you know, those are, these are all not, they’re not things I think that your everyday therapist can do. But, but I think there are things that the profession as a whole needs to be looking to toward and models that need to be done, where we can demonstrate that value based care can give you a return on investment that is not just better for us as individual therapists, but also better for the real payers of the world, you know, the government and the employers.

So we’re talking about pain. So I think, you know, people familiar with, okay, um, this intervention in my office would help with pain. It’ll reduce disability. Um, it’ll reduce the use of medication, surgery, um, scans, things like that. Do we need to elevate? That’s all good that we should all, we should all be preaching that. I think we do to a certain extent, but should we start to also elevate the conversation to this type of value-based care delivered by a physical therapist or another professional, let’s say a chiropractor? When it’s delivered in this way, not only does it reduce the things we just mentioned, but it also improves overall physical health, things like cardiovascular disease, diabetes, as well as mental health, which I think is an important topic right now in the United States of America, which has an intimate relationship with chronic pain.

Yeah. And take this a step further and say, and what if you’re an employer? Aren’t you going to have a more productive employee?

Sure. Yeah.

You’re gonna have a person that has less time off work. You’re gonna have a person that is, you know, if they’re happier, you know, in general and not in pain, they’re generally gonna be a nice person to be around and their colleagues are gonna like them and it’s gonna be a more productive unit. You know, these are the kinds of things we laugh, but these are the kinds of things that employers want. Don’t get me wrong, they wanna have people with less pain, they wanna have people with less depression and everything else, but a more productive workforce, You know, that’s a huge deal for employers.

I mean, I’ve worked in HR capacity myself, primarily through hiring healthcare professionals. And I can tell you one of the most stressful things is not just when someone’s out sick with pain, so to speak, but if you have to replace an employee, which oftentimes happens in these circumstances, that costs companies, you know, oftentimes it’s almost like five to 10 times the salary of someone to replace them if they leave a job, so to speak.

And then imagine yourself now in a big operation, like Intel. Intel was looking at the spend and they were saying to themselves, this has got to stop. We can’t keep doing this. And their experience probably mirrors many, many other large industry. And to me, it’s a wonder that they’re just not attacking this much more aggressively.

Well, essentially, because even I think a lot of our topic in some way has centered around back pain being embedded in a medical model, so to speak. But I think we’ve transitioned, or we have transitioned probably in the last 30 minutes, is that we really need to kind of maybe take it out of the medical model, put it in more of a workplace community-based model where we’re really talking about more health and wellness, so to speak, I think.

Exactly. And if you have that, If you have that in place, more health and wellness, then your goal becomes keep people away from that medical model as much as possible, but not the approach of I’m gonna ration care. Just give people alternatives, give people self-management alternatives. Give that first impulse where you’re gonna, I’m gonna go see my physician or I’m gonna go to the emergency room. Is there a self-treatment? kind of approach that you would have where maybe there’s some health coaches or maybe there’s even a PT around that you can get to immediately and they can kind of quell that whole thing and just even if you’re 30% successful how much will you save that self-insurance fund if you did something like that and is it going to and is that going to more than offset the cost of whatever that is that you’re putting in place whether it’s a coach whether it’s a PT or something else that those kind of things are are really worthy of discussion and then You know, to me, the, you know, nirvana to me is to have one of, is every employer should have, you know, sort of a wellness center, you know, where people can go and manage their chronic conditions first. And the opportunity of last resort is to go to the emergency room or go to the primary care physician. You know, just think of what you’d save there. And, you know, in my estimation, these self insurance funds have to be have to have millions of dollars in them. You know, because they’re constantly paying out, you know, for these hospital bills, wouldn’t it be wouldn’t make sense to invest from there and something like this. And that’s where the money will be saved. And then it’s all in that self insurance fund. And I often wonder just what the cost benefit of that would be.

Yeah. That’s why when I wrote the PRISM model, people said, this is kind of big. And I said, well, it is big, but sometimes, you know, to, to solve a big problem, like we might need something that seems a little bit bigger and you might not use all of it, so to speak, but you need kind of a bigger approach to tackle these bigger problems. Tony, it’s been great speaking to you today. I’m sure people are going to want to learn more about you and read all your research. You have years of decades of research in this area. Let people know how they can learn more about you and follow your work.

So, yeah. I mean, I’ve left some, some, some, some, some, you can certainly look at my, you know, look me up on pit.edu, shrs.pit.edu. And I have a link with all of my publications that that’s available. But I think one of the things that that you might not see on these links. I’ve said about three or four, right after the target trial, I said, if I have more research in me and my career, it’s going to be in the implementation mode. Rather than discover a new way to treat something, I think really what we need to do is take what we know and try to get it implemented. 

Well, we’ll be looking out for those numbers. I know you’ll eventually publish something in that area. Um, I want to thank Dr. Anthony Delitto for joining us this week on the pain science education podcast. Of course, all the links to his work you can find on the show notes at the integrative pain science Institute. If you know someone who’s interested in high value care for back pain or chronic pain in general, please check out this episode and share with your friends and family on Facebook, LinkedIn, Twitter, or anyone is talking about high value care in pain care. I’m Dr. Joe Tatta. Thanks for joining me. We’ll see you next week.