Physical therapy: sometimes useful; sometimes not

I’ve been to several physical therapists over the years. When I was in my mid-forties, I split my kneecap in half, requiring an ankle-to-groin cast that resulted in atrophied thigh muscles. In that case, my physical therapy was crucial in helping me regain muscle strength in my quadriceps and flexibility in my knee. In subsequent years, I’ve been to physical therapists for hip pain. In those cases, the therapy was useless. Most recently I’ve been to physical therapy following knee replacement surgery. Those sessions were useful, mostly because of the equipment, such as the leg press machine and stationery bicycle, that I don’t have at home.

According to an article in The New York Times, “there’s been a quiet revolution taking place in the field of physical therapy.” That “revolution” is basically an effort to create evidence-backed treatment guidelines. (Duh.) For example, evidence has shown that exercises to increase quadriceps strength after an A.C.L tear get an A. Electrotherapy to improve heel pain for plantar fasciitis gets a D. As a rule, most “passive” treatments, such as electrotherapy, lasers, ultrasound, heat, and icepacks have been deemed useless. (Ice packs prevents blood and inflammatory cells from reaching the damaged tissues—but blood and inflammatory cells are a necessary part of the healing process. Using ice can delay or prevent recovery.)

What works are exercises that improve strength and flexibility, as well as ergonomic adjustments to prevent future injuries.

Most important, in my view, is a response to the article by a practicing physical therapist bemoaning the fact that “…patients often approach their healthcare with a less-than-optimal sense of agency about their own role in their rehabilitation. Far too many of the people who come to me following a surgery have little to no idea of what was done to them or what the implications of their procedure might be. …The best physical therapy, in my view, promotes patient responsibility…” Amen to that. I am still working diligently to improve the flexibility of my knees. 

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Corporate investors in primary health care

Corporations are increasingly investing in primary health care. For example, last year Amazon announced plans to acquire One Medical—a primary care organization with nearly 200 locations serving more than 700,000 patients. The price: $3.9 billion. Those 700,000 patients are a revenue stream. As an article in The New England Journal of Medicine notes, “Primary care practices can generate substantial profits by growing their population of patients covered by Medicare Advantage.”

This trend toward corporate investment in primary care is driven by a model called “value-based payment," in which Medicare and commercial players hold providers financially accountable for the cost and quality of the care they deliver. Instead of fee-for-service reimbursements, a physician or group of physicians receives a “risk-adjusted” amount of money for each person under their care regardless of the volume of services that person uses. This payment arrangement is called “capitation” and uses risk adjustment to predict a the cost of each person's health care services. The risk adjustment score considers each person’s demographic, such as age, and disease factors, such as whether the person has diabetes, HIV, or heart disease. The score determines the amount of money the medical practice receives for each person—the higher the score, the more money the practice receives.

The purpose of value-based payments is to reward providers financially for delivering better, more cost-effective care. The problem is that the providers can increase profits by maximizing the “budget” for each patient’s care. They maximize the budget by increasing a patient’s risk score. They increase the risk score by “upcoding” his or her diagnoses. (Codes are alpha-numeric designations for each disease diagnosis. For example, HCC34 is the code for chronic pancreatitis.) The diagnosis of a patient with a cough and a fever could be upcoded to a diagnosis of pneumonia. 

Studies have shown that between 2006 and 2011 risk scores for Medicare Advantage beneficiaries were 6 to 16% higher than they would have been under traditional fee-for-service Medicare. You can count on Amazon to know how to make a buck.

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The new weight loss drugs

I recently learned about a new weight-loss drug that's been approved by the FDA. It's called called Wegovy (scientific name semaglutide). It began as a drug for diabetes called Ozempic. People taking Ozempic lost weight. So the drug company, Novo Nordisk, increased the drug's active ingredient and gave it a new name (Wegovy) and marketed it for weight loss. A clinical trial of Wegovy in 2018 showed that people lost an average of about 15 percent of their weight over 16 months. 

Wegovy is a prescription medicine for people who are obese (body mass index of 30 or more), or overweight (body mass index of 27 or more). Incidentally, my body mass index is approaching 27, indicating that you don’t have to be very fat to get a prescription.

The drug, which you take by weekly injections, works by mimicking a hormone that reduces appetite by signaling the brain to make the stomach feel fuller. Side effects include nausea, vomiting, and diarrhea, but apparently those effects diminish after a while. Insurance coverage has been spotty, primarily because insurers view the drug’s purpose as cosmetic, although this seems to be changing. For now, some consumers are paying as much as $1,500 a month. Wegovy may soon have its first major competitor in Eli Lilly’s Mounjaro (tirzepatide). In a clinical trial, most people lost at least 20% of their body weight. 

Doctor Samuel Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis says “These really have had a dramatic effect on body weight that we haven't seen before. Getting 15%, 20% weight loss was very difficult to achieve with the previous medications.”

This is looking like a massive potential market. A July 2022 report from Morgan Stanley notes that obesity drugs are “set to become the next blockbuster pharma category.” The market could reach $54 billion by 2030. Maybe they should consider catchier names.

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Rewarding doctors for prescribing

 Rewarding doctors for prescribing medicine is a long-standing practice among many—if not most--pharmaceutical companies. The rewards consist of payments for consulting services and for participating in a speakers’ bureau. For the most part, however, the doctors don’t consult; neither do they give speeches at conferences.

Recently, former employees of Biogen, which makes drugs for multiple sclerosis, sued the company for just that sort of wrongdoing. Nearly half of the doctors who wrote more than 1000 prescriptions per year for MS medications received consulting payments from Biogen. Biogen settled the case for $900 million.

 Biogen focuses on specialty drugs—those with list prices higher than $50,00 a year. Such drugs, according to the New England Journal of Medicine, “are the most important drivers of profitability in the pharmaceutical industry; relatively few prescriptions for such drugs can generate substantial revenue.”

Pharmaceutical companies want you think that the high cost of the drugs is necessary to pay for the costs of drug discovery. But, according to the NEJM, many pharmaceutical firms spend as much or more on sales and marketing as they do on research. Manufacturers paid doctors nearly $1 billion to be consultants or speakers in 2016. Some of these funds could instead be put toward drug discovery and could help cover any shortfalls that may occur as a result of the new legislation (Inflation Reduction Act) that allows the federal government to negotiate the prices it pays for certain medications.

Negotiations on drug prices refer only to Medicare, of course. What about everybody else?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Cartoon for the holiday