Thursday, July 30, 2009

Recurring philosophical questions

I have had a recurring question in my mind since the beginning of my occupational therapy career. At that time I was working in an urban acute care psychiatric facility and I was fresh out of college with my head full of lofty ideas about occupational behavior, occupational role, and the potential of occupational therapy to solve societal problems.

I read every word that Mary Reilly ever wrote, and listened as they were explained to me in the classroom by proxy of Phil Shannon and watched in amazement as they were practiced in a hospice home care setting while being mentored by Kent Tigges. Still, after work each day I took the Metro North to the safety of suburban living and I kept rolling over the question: "How can I remember NOT to transpose my values and my concept of Quality when working as an occupational therapist??"

My training told me that I wanted my patients to develop options, decision-making, problem solving, and agency relating to some return to occupational role. This was easy to comprehend if I was dealing with people who were students, homemakers, or workers but most of the patients that I saw were none of these things, nor did they aspire towards them. I was treating chronically ill people, people who were drug addicted, people who were on welfare or who were 'professional' patients.

The concept of helping people achieve occupational role functioning seemed like a very white and upper middle class attitude - which from the perspective of that particular demographic is not a bad way to organize the world with respect to sociology, economics, etc. - but it was anathema to THE SYSTEM and the real experiences of most of my patients. It just wasn't their brand of real.

So the idea of cultural competence comes into play, but for all the chatter about cultural competence it doesn't seem to bridge the gap between our theory base and the lived experience of many people who receive our services. I am not certain that we are improving and despite some of the wonderful advances in theory since the late 1980s I see that the divide remains as a real problem for our profession.

In concept I enjoyed Yerxa's article in the new AJOT, entitled "Infinite distance between the I and the It." I appreciate good philosophy and in many ways I can understand exactly what she is driving at - but the more I read the more I heard the repetitive tha-thunk and whoosh of the Metro North car as it sped toward the safety of the suburbs. The problem is in the basic premise where she writes, "Our purpose is to enable people to become agents of their intentions and to obtain satisfaction through actualizing their unique interests" (p. 491). I think this is often true but it is not always true.

Today I walked into a family's apartment; my responsibility is to provide early intervention services to a little two year old in the home. The family unit is comprised of the mother who works part time and receives welfare assistance, a boyfriend who is developmentally disabled and at least 40 years older than the mother, and the child. They live in abject poverty: there are no toys, there is little food, there is no money. The boyfriend was watching the child, and I immediately noticed the large and oozing hematoma on his forehead when he answered the door. It was hard to get information from him because he was frightened that his girlfriend would be mad but he eventually revealed that she hit him in the head with a pot because somehow the baby knocked the television off of the table. I'm not sure how these events are connected but that was his report. He was planning on going back to his home in a neighboring city, but he wasn't sure if he had the bus tokens to get him there.

Although the details are unique, the flavor of this scenario is not unique. The people in this story are not poised to receive a health service that helps them self-actualize. They need a service that respects their human dignity, provides them with a means of economic survival, and perhaps - if good fortune abounds - helps them develop skills for autonomy and independence that may one day lead to the beginning steps of self-actualization.

Similarly, we get 'thank you' notes from our patients constantly for the fine work of the therapists in our clinic that focuses on hand injuries. The notes always say the same kind of things: '"Thanks so much for helping my hand get better!" and "I am so happy that I was able to go back to work." I have not yet received a thank you letter that states, "Thank you for helping me determine how I will make a contribution with my life." Now in obtuse ways one could argue that the patients are indeed 'saying' this but I don't think so. I don't think that most people really think in those terms. Sure - some do - like Florence Clark's patient that she discussed in her Slagle lecture. But most patients are not asking us to conduct and compose metaphorical and allegorical tales to help them find meaning in their disability experience. In this sense I think that our theory is at risk of missing the mark on the lived experiences of many people who actually receive occupational therapy services. Many folks are happy to move their hands again - or happy to pick up their grandchildren again. For them, occupational therapy is not an "ethical quest, promoting human flourishing" (p. 496).

The 'I' that Yerxa discusses is so critically important - and I really do agree in part with what she is saying.. but not all of those I people live their I experience in the way she describes. Sometimes, people even subjugate their I in consideration of the larger cultural context - because the cultural context is sometimes more important than the I! A very clear example that comes to mind here is literary - the character Okonkwo in the novel Things Fall Apart. Okonkwo rigidly adheres to his cultural traditions - even though they lead to his own exile and eventually bring him into conflict with the introduction of Christianity - a conflict that causes him to commit suicide. There was no I for Okonkwo, or perhaps his I was defined by the We of his clan and its customs. In this case, would occupational therapy help the we flourish or would it help the I flourish? I am not sure.

The overall point here is that there is danger in assigning our personal values to Quality - and I believe it is possibly wrong-headed to believe that the self-actualizing, meaning-pursuing, and Forrest Gump questions of 'What's my destiny, mama?' are reflective of how everyone really experiences their lives.

This kind of philosophizing about the meaning of living kind of works for me, but I am a white upper middle class guy. When I try to think fairly and I think of the guy who has developmental disabilities and who literally has no resources and perhaps fewer options and is scraping up bus tokens to escape the domestic abuse of his girlfriend - it just becomes difficult to imagine his lived experience in terms of the word 'flourish.'

I think that there is something more germane to OT than a highfalutin preoccupation with I. I think it may have something to do with the basic dignity of human experience, and perhaps meeting needs across a broad spectrum of perspective - especially and particularly when that perspective has to do with finding ways to duck from flying pots.


Achebe, C. (1958) Things fall apart. New York: Anchor Press.

Yerza, E. (2009). Infinite distance between tne I and the It. American Journal of Occupational Therapy, 63, 490-497.

Monday, July 27, 2009

Fun-filled game of the day: Guess the CSE chairperson's intent!

Why would a CSE chairperson who has worked in the field for over 20 years suddenly want more information on the Beery VMI?? This chairperson has seen this assessment used hundreds of other times... so why more information now??

Inquiring therapists want to know.

re: Johnny XXX

To Whom it May Concern:

At the request of the district CSE Chairperson, here is additional information regarding Johnny's performance on the Beery VMI. Quite honestly this is an unusual request as this test is perhaps the most commonly used assessment in school-based occupational therapy and I do not understand why special explanations are required for this child. I am hopeful that this information will help to get an appropriate plan for this child into place.

The Beery Developmental Test of Visual Motor Integration 5th Edition is a widely respected assessment tool that is backed by decades of research and clinical use. The Beery VMI screens for visual-motor deficits that can lead to learning, neuropsychological, and behavior problems. The assessment is commonly used by occupational therapists as part of an overall evaluation for school-related performance difficulties.

The Beery VMI helps assess the extent to which individuals can integrate their visual and motor abilities. The tests present drawings of geometric forms arranged in order of increasing difficulty that the individual is asked to copy. The Beery VMI series also provides supplemental Visual Perception and Motor Coordination tests to help compare an individual's test results with relatively pure visual and motor performances. (One or both of the supplemental tests may be used.) The purposes of these additional tests is to allow for a statistical comparison of results from all three tests.

Many therapists use the Motor Free Test of Visual Perception 3rd Edition instead of the Perception component of the VMI. As stated above, the comparison results are helpful to determine if a child's writing difficulties are perceptual or motor based.

In the instant case, the child scored a standard score of 137 on the perceptually oriented MVPT-3 and a standard score of 78 on the Beery VMI. This represents a 59 point difference - almost 4 standard deviations of discrepancy between the scores. This indicates that the child has advanced perceptual abilities but has severe disabilities in operationalizing this perceptual skill into the motor act of writing. This discrepant performance was already clearly spelled out in the child's recent OT evaluation that is being questioned.

As corroborating evidence, the child has extremely poor organizational skills and his writing is only marginally legible.

If any additional information is required please do not hesitate to contact me.


Christopher J. Alterio, Dr.OT, OTR
Occupational Therapist

Thursday, July 23, 2009

We need consumer education and tort reform before handing over health care to our government

There are many conversations swirling about regarding health care reform, proposed 'public options,' and tax/penalty methodology to pay for the programs. The more that gets said the less specificity seems to be revealed. Instead I am hearing a lot of lofty and non-specific theory that the system will pay for itself by 'inherent efficiencies' which I have concern may be code for rationing. When pressed for these kinds of details all I am hearing is a full-frontal assault on 'insurance companies' but occasionally there is a jab slipped in at providers who are accused of making decisions based on reimbursement structure and not on clinical necessity.

There is no doubt that a reimbursement system obviously creates incentives and disincentives to how care is delivered - but to accuse providers of driving decisions solely on financial incentive is a little much. The added insult is to trumpet the 'endorsement' of prominent organizations - like the AMA - which informed people know does not actually represent the opinion of all or even most physicians.

All that aside, I think there are two essential reform components that our health care system needs and I don't hear a lot of conversation about them. These two missing components are education and tort reform. Anecdotes help people understand issues - so rather than list statistics that tend to make people's eyes glaze over I want to tell two very recent stories that help to illustrate these needs.

First is the need for education. This morning I had a patient call me and he was concerned about his bill. The bill was extremely straightforward. He injured his hand and required very short term therapy that included splinting and two weeks of guided exercise, control of inflammation, and a home program educating him on how to promote healing and slowly return to his normal tasks. He had five co-pays and his insurance company only reimbursed half the cost of his splint. His insurance company sets the reimbursable allowance of each therapy visit and of the splint. His cost was actually quite modest and completely consistent with the HMO model of 'cost-sharing' where the insurance company pays part of the cost and the patient pays the 'co-pay.' The patient was upset that he incurred costs at all and although he understood the explanation he stated, "Well I just guess that I didn't expect a bill, and I guess my health insurance just sucks."

Of course no one is happy when they receive a bill, and I am sure that everyone would like to have free health care - but this fellow didn't understand how health insurance really works and had no real appreciation for the concepts of 'co-payments' and cost-sharing as a model for insurance. Based on my experience his opinions are not unique: many people think that if they have insurance that they are then 'covered.' Many people can't understand how insurance works. They don't understand co-pays. They don't understand deductibles. They don't understand coverage limitations. People can consume health care more responsibly if they are educated - and this is a sorely needed component.

A second component is tort reform. Medical malpractice liability forces providers into practicing 'defensive medicine;' in other words, it causes providers to order tests and to perform procedures 'in defense of' potential lawsuits JUST IN CASE they miss something in a patient's case. Here is another recent example - this one personal.

My daughter complained of deep hip pain the other day and since she is an active risk taker my first question to her was "Is there any REASON why your hip would hurt - did you fall, or were you running or biking or ANYTHING??" Of course she said there was no reason for it so that raised my alert level a little. In drum corp she recently started hauling around the large bass drum and that was new so I started to think that her symptoms could be related to her new bass drum playing. Now I don't like overusing the medical system and I am very conservative, but this is where too much knowledge can cause difficulties. Although my daughter is not obese by any measure, she has been carrying around a bass drum for many hours and this adds to her functional weight and strain on her lower extremities. Then I started thinking that she is in the middle of adolescence and growth spurts. Being the therapist that I am I started putting two and two together and began thinking that there was a small chance that her sudden unexplained hip pain could be related to a slipped capital femoral epiphysis. I asked her again if there was ANY OTHER REASON for her pain and she said there was not. So, I broke down and decided to let the pediatrician see her.

The pediatrician, who is extraordinarily and appropriately diligent, ordered an x-ray of the hip which was negative. I am sure that several differential diagnoses were circling around in the MDs mind - although I did not ask her thought process. I am sure she was thinking, strain, hairline fracture, SCFE, hernia, and any other number of possibilities. Then the pediatrician asked again, "Is there ANY OTHER REASON why your hip would hurt?" Dutifully, my daughter then recounted a story where she and her friend were practicing yoga and her friend was stretching her leg. Oh, and this all just happened last night.

Of course I wanted to kill my daughter at this point because by now we had gone to the MD, wasted the MD's time, gotten an xray and perhaps killed off or mutated a few eggs in the process - all for the sake of a probable muscle strain caused by silly adolescent girls doing yoga at a slumber party. If I had this information I would have avoided the MD visit and xray - and just watched it a couple days with the anticipation it was a self-limiting and minor muscle strain. But here is where the doctor and I separated.

Although the MD acknowledged that it was all just likely a muscle strain - she also had to suggest that the only way to rule out everything else was with an MRI. That would mean an additional expensive test, a consultation with a radiologist to read the report, and more follow up with the pediatrician. I politely declined - and decided to just watch her at home. Turns out that it was just a muscle strain after all and she is fine now.

The point here is that you can see how engagement in the medical system leads to an upwardly increasing spiral of interventions - all in consideration of not wanting to possibly 'miss' something. If indeed my daughter had a SCFE or a hernia and that MD didn't order the MRI then they would be liable - and this is no small issue - A SCFE could lead to avascular necrosis of the hip and a hernia could lead to a strangulated intestine. No MD in their right mind would want to leave those stones unturned - especially in this litigious society. Tort reform could limit medical liability to reasonable levels and have a suppressing effect on the excessive use of expensive diagnostic tests. This would save uncounted billions in health care costs but is not a strong component in any of the health care reform proposals.

We need consumer education on how insurance plans work and how they can best function and make decisions in our current system. We also need to relieve practitioners of the pressures associated with practicing defensive medicine. These are examples of two important issues that are nowhere to be found in our current conversations about health care reform.

Thursday, July 16, 2009

The impact of proposed new federal regulation on health care delivery

Proposed new health care regulations may have an extraordinarily negative impact on the way consumers access their health care. The following information is from a September 2005 report from the Small Business Association entitled The Impact of Regulatory Costs on Small Firms.

"The annual cost of federal regulations in the United States increased to more than $1.1 trillion in 2004. Had every household received a bill for an equal share, each would have owed $10,172, an amount that exceeds what the average American household spent on health care in 2004 (slightly under $9,000). While all citizens and businesses of course pay some portion of these costs, the distribution of the burden of regulations is quite uneven. The portion of regulatory costs that falls initially on businesses was $5,633 per employee in 2004, a 4.1 percent cost increase since 2000 after adjusting for inflation. Small businesses, defined as firms employing fewer than 20 employees, bear the largest burden of federal regulations, as they did in the mid-1990s and in 2000. Small businesses face an annual regulatory cost of $7,647 per employee, which is 45 percent higher than the regulatory cost facing large firms (defined as firms with 500 or more employees)."

In other words it is fact that small employers (particularly those with fewer than 20 employees) share a disproportionate burden of regulatory costs. This is important to consider because of the current debate regarding health care reform that will cause additional mandated cost burdens to small health care practices.

A lot of people consume their health care in 'very small businesses' - your doctor, physical or occupational therapist, dentist, mental health counselor, chiropractor, etc. are mostly categorized as 'very small businesses.' Many of these offices employ small numbers of people - but interestingly the payrolls of these operations are high because they are employing a highly skilled professional workforce.

How might the current health care reform proposals impact these employers? In the current text of H.R.3200 as Introduced in House as America's Affordable Health Choices Act of 2009 there are significant penalties for employers who won't be able to afford to offer health care for their employees - as much as 6% for payrolls between $350k to $400k per year.

These payroll sizes are actually quite small, and will likely have a disproportionately negative impact on small professional offices where the average salary is high. Specifically, how many health care workers can be employed under a cap of $400,000??? The answer is "not many" and that is why these salary cap proposals are extremely damaging to small offices that employ these highly paid professionals.

These penalties will be applied to many of these provider offices because they may not be able to afford the proposed mandatory percentage contributions, which are currently proposed as:

72.5% of the premium cost of single coverage
65% of the premium cost of family coverage

The critical factor here will be the cost of the premiums, of course - which is a rather large unknown at this point. Still, the owners of these medical and professional offices will be forced to incur increased costs - either through mandated premium contributions or penalties for not participating. Increased employer expenses drive up the cost to deliver care, which will lead to upward pressures on prices - which ultimately feed pressures on cost to deliver that care -and on and on in a never ending upward spiral.

An alternative is that employers will seek to limit the size of their practices and control their functional growth - which essentially subverts the system by ducking underneath the mandates. The problem with this is that it bypasses the intent of making insurance affordable/available and it forces care to be delivered by increasingly small offices which is not efficient and also can also cause upward cost pressures.

If small professional offices are not able to find ways to work within these systems they will ultimately fail. That can cause consumers to have fewer choices or to force consumers into very large health care systems that are able to work within these models because as stated above the relative cost distribution of these mandates is less on large employers.

This will be a shock for consumers - most don't prefer standing in the waiting room with 50 other people who are all waiting to see the same doctor and who were all given a 9am appointment. This is the model of care in large inner city clinics - and won't sit well with people who are more used to receiving their care in their small community doctor's office.

So the future of health care delivered in small professional offices is at risk - unless the reimbursement structure offered somehow offsets the mandated costs. That will keep the small professional offices in "business" and preserve consumer choice but will certainly not do much to help limit the cost of that health care, which was supposed to be the whole point from the beginning.

From the perspective of a small health care provider, the intent of the proposed legislation seems to be the systematic decimation of our current delivery system. There is no question that we require reform in our system but this proposal is a frontal assault on the doctor, dentist,and therapist in your local community. It will have a chilling impact on what your future health care delivery will look like.

End game analysis: get ready to drive to the big hospital clinic, grab a number, and stand in line. It's the only way that the proposed model can be affordably delivered.