Transcript Why OMM

Why OMM ?
WILLIAM C. SIMON DO
NEW MEDICAL HEALTH CARE
What is OMM?
Osteopathic manipulation is a treatment that
attempts to improve joint range of motion
and balance tissue and muscular mechanics.
Improve function and decrease pain and
suffering
What is OMM used for?
 Headaches
 Back pain
 Shoulder dysfunction and pain
 Carpal Tunnel Syndrome
 Strains and sprains
 SOB
 Chest pain with rib dysfunction
 Colic
 Just to name a very few
OMM is used to treat:
 musculoskeletal pain conditions, such as back pain,
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shoulder pain, arthritis, and tension headaches .
Some advocates of OMT believe that it has
numerous other benefits, including:
Upper respiratory infections
Fibromyalgia
Asthma
Carpal tunnel syndrome
Pneumonia
Bronchitis
Overall health and well-being
Osteopathic history
Evolution of Osteopathic Medicine
 Evolution of osteopathic medicine's mission
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and identity took Years to evolve:
1892 to 1950 Manual medicine
1951 to 1970 Family practice / manual therapy
1971 to present Full service care / multispeciality
orientation
1916-1966, Federal recognition
 Recognition by the US federal government was a key goal of the
osteopathic medical profession in its effort to establish equivalency
with its MD counterparts. Between 1916 and 1966, the profession
engaged in a "long and tortuous struggle" for the right to serve as
physicians and surgeons in the U.S. Military Corps
Years States Passed unlimited practice rights for
DOs, equal to those of MDs
● Early, 1901-1930
● Middle, 1931-1966
● Late, 1967-1989
Osteopathic
Schools in
red
Percentage
of all
physicians
Percentage
Colors from
light to dark
●Geographic distribution of osteopathic physicians as
a percentage of all physicians, by state.
<3%
3-5%
5-10%
10-15%
15-25
Osteopathic Medical Schools
 Midwest
& Plains AT Still Kirksville, Des Moines COM, Kansas City COM, Michigan
State, Midwestern Chicago, Ohio COM, Oklahoma State
 Northeast Lake Erie COM, New England COM, New York COM,
Philadelphia COM, Touro Harlem, UMDNJ-SOM
 Southeast Lake Erie COM, Bradenton, Lincoln Memorial, North Texas
COM, Nova Southeastern, Philadelphia COM Georgia, Pikeville KYCOM,
Virginia COM, West Virginia SOM, William Carey COM
 West AT Still Arizona, Midwestern Arizona, Pacific Northwest, Rocky Vista,
Touro California, Touro Nevada Western
 Currently, there are now 26 accredited osteopathic medical schools offering
education in 34 locations in the United States and 126 accredited US (MD)
medical schools.
Osteopathic Schools
 In 1960, there were 13,708 physicians who were
graduates of the 5 osteopathic medical schools.
 In 2002, there were 49,210 physicians from 19
osteopathic schools.
 Between 1980 and 2005, the number of osteopathic
graduates per year increased over 250 percent from
about 1,000 to 2,800. This number is expected to
approach 5,000 by 2015.
Osteopathic Training
The osteopathic medical school curriculum is
clearly distinguished from allopathic medical
education by its focus on osteopathic
manipulative medicine (OMM), a hands-on
therapy that is used to diagnose and treat illness
and injury. OMM education usually occurs
through year-long first and second year
theoretical and skills courses, and through
subsequent clinical experiences. OMM education
is in addition to, and integrated with, medical
training on current and emerging theory and
methods of medical diagnosis and treatment.
Osteopathic Training and Trends
 Osteopathic medicine is considered by some in the
United States to be both a profession and a social
movement, especially for its historically greater
emphasis on primary care and holistic health.
However, any distinction between the MD and the
DO professions has eroded steadily; diminishing
numbers of DO graduates enter primary care fields,
fewer use OMM, holistic patient care models are
increasingly taught at MD schools, and increasing
numbers of DO graduates choose to train in nonosteopathic residency programs.
Trends in Osteopathic Primary Care
Trends in primary care as a career choice of osteopathic medical students
4th year students-dark blue
1st year students-light blue
Physicians Entering the Work Force
Graduate Medical Education
Total Number of DO’s in Residency Training
Programs, by Year.
Blue is DO residents in
ACGME (MD) programs.
Red is DO residents in AOA
(DO) programs.
Manipulation in Practice
 A 2001 survey of osteopathic physicians found that
more than 50% of the respondents used OMT on less
than 5% of their patients. The survey follows many
indicators that osteopathic physicians have become
more like MD physicians in every respect —few
perform OMT, and most prescribe drugs or suggest
surgery as a first line of treatment.
Manipulation in Practice
 Recent studies show an increasingly positive attitude of
patients and physicians (MD and DO) towards the use of
manual therapy as a valid, safe and effective treatment
modality. One survey, published in the Journal of
Continuing Medical Education, found that a majority of
physicians (81%) and patients (76%) felt that manual
manipulation (MM) was safe, and over half (56% of
physicians and 59% of patients) felt that manipulation
should be available in the primary care setting. Although
less than half (40%) of the physicians reported any
educational exposure to MM and less than one-quarter
(20%) have administered MM in their practice, most
(71%) respondents endorsed desiring more instruction in
MM.
Manipulation in Practice
 Another small study examined the interest and
ability of MD residents in learning osteopathic
principles and skills, including OMM. It showed that
after a 1-month elective rotation, the MD residents
responded favorably to the experience
OMM vs Standard Medical Treatment Study
 A Comparison of Osteopathic Spinal
Manipulation with Standard Care for
Patients with Low Back Pain
 Gunnar B.J. Andersson, M.D., Ph.D., Tracy Lucente,
M.P.H., Andrew M. Davis, M.D., M.P.H., Robert E.
Kappler, D.O., James A. Lipton, D.O., and Sue
Leurgans, Ph.D.
 N Engl J Med 1999; 341:1426-1431November 4, 1999
OMT Study
 They performed a randomized, controlled trial that
involved patients who had had back pain for at least
three weeks but less than six months. They screened 1193
patients; 178 were found to be eligible and were
randomly assigned to treatment groups; 23 of these
patients subsequently dropped out of the study. The
patients were treated either with one or more standard
medical therapies (72 patients) or with osteopathic
manual therapy (83 patients). They used a variety of
outcome measures, including scores on the Roland–
Morris and Oswestry questionnaires, a visual-analogue
pain scale, and measurements of range of motion and
straight-leg raising, to assess the results of treatment
over a 12-week period.
OMT Study Results
 Patients in both groups improved during the 12
weeks. There was no statistically significant
difference between the two groups in any of the
primary outcome measures. The osteopathictreatment group required significantly less
medication (analgesics, antiinflammatory
agents, and muscle relaxants) (P< 0.001) and
used less physical therapy (0.2 percent vs. 2.6
percent, P<0.05). More than 90 percent of the
patients in both groups were satisfied with their care.
Cervical OMM
Cervical Manipulation and Stroke Risk
 Stroke with cervical manipulation is estimated to be
1 in 400,000 to 1 in 5.8 million
 NCMIC Chiropractic solutions concluded: “the
incident of stroke in the population as a whole is no
different, with about 2 per 100,000 anually, than
those who received manipulations of the neck.”
Cervical OMM
 Neck strains
 Headaches
 Sinus Problems
 Stiff neck
 Arm numbness
Cervical Manipulation has Lots of Techniques
Thoracic Manipulation
Thoracic Manipulation
 SOB with rib release
 Chest pains (not cardiac
related unless stable)
 Upper back pains
 Shoulder pains
 Lots of people have pains in
this area from purses,
backpacks and leaning over
to do daily work
Lumbar Manipulation
Lumbar Manipulation
 Majority of back issues
 Sciatica
 Radiculitis
 Abdominal pain
 Usually spasms are cause for most pain
 Obesity is a contributal cause
 Related to daily activities such as lifting, twisting,
stooping and bending
McRib and McBack Pain
Obesity, Back Pain and Workers’ Comp
 Obesity was particularly
linked to workers’ comp
claims for falls, slips,
lifting, exertion, back
pain, and injuries to the
hand, wrist, knee, hip
and ankle!
 Physically demanding
jobs carry the greatest
risks!
Obesity, Back Pain and Worker’s Compensation
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Medical costs per 100 workers
Normal BMI: $7,500 (18.5-24.9)
Overweight: $13,300 (25.0-29.9)
Mildly Obese: $ 19,000 (30.0+)
Moderately Obese: $23,000 (>40)
Severely Obese: $51,000 (>50)
 Researchers found that the number of workdays lost was
almost 13 times higher, medical costs 7 times higher and
indemnity claims costs were 11 times higher among the
heaviest employees compared to those of normal weight
Medical Costs of Back Pain Related to Obesity
Back Pain
Medical costs per 100 workers
$51,000
$19,000
$23,000
$13,300
$7,500
Normal BMI
Overweight
Mildly Obese
Moderately
Obese
Severely Obese
Back Pain is a Leading Cause of Work-Loss Days
 83 million days of work are lost each year due to
back pain
 Back pain is a leading cause of work-loss days as well
as work limitations.
 Adults with back pain spend almost 200 million days
a year in bed!
 A larger proportion of back pain patients report
feeling sad, worthless or hopeless.
Days Lost from Work for Various Injuries
Neck, 2%
Head, 7%
Body /Multiple
parts, 10%
Lower
Extremities,
21%
Upper
extremities,
23%
Trunk, 12%
Back , 25%
Proportion of Adults with and without Back Pain
Who are Working
100
90
80
70
60
With back pain
Without back pain
50
40
30
20
10
0
18 to 44
45 to 64
65+
Median Annual Earnings of Adults With Work
Limitations Due to Back Pain, by Age
Median Income
With Back Pain
$29,700
$23,160
$21,909
$15,600
18 to 44
45 to 64
Without Back Pain
Adults With and Without Back Pain Using
Various Health Care Services
Without Back Pain
Physical or Occupational Therapist
2
Chiropractor
2
With Back Pain
8
20
Physician visits
66
Prescription drugs
65
83
83
Health Care Expenditures for Adults With and
Without Back Pain
Health Care Visits
Without Back Pain
With Back Pain
Prescription Drugs
244
Physician Visits
Non-Physician Visits
ER Visits
367
223
103
370
203
275
304
Effects of Back Pain on Retirement
With Back Pain
Without back pain
Satisfaction with
retirement
with back pain
Satifaction with
retirement
without back pain
Not at all
Moderate
Very
Not at all
12%
Moderate
6%
29%
50%
38%
65%
Very
Cost of Back Pain
 In 2005 Americans spent $85.9 billion looking for
relief from back and neck pain, through surgery,
doctors’s visits, xrays, MRI’s and medications.
 This is up from $52.1 billion in 1997.
 According to the JAMA, that money has not helped
reduce the number of sufferers; in 2005, 15% of U.S.
adults reported back problems, up from 12% in 1997
Cost of Back Pain
 Researchers at the University of Washington and
Oregon Health Science University compared national
data from 3,179 adult patients who reported spine
problems in 1997 to 3,187 who reported them in
2005 and found that inflation adjusted costs
increased from $4,695 per person to $6,096.
Cost of Back Pain
Number with back pain
$6,096
$4,695
3,187
3,179
1997
2005
Cost of treatment
Was That in the P.I.?
Chiropractic Cost-Effectiveness
 Blue Cross Blue Shield of Tennessee conducted a
study in 2010 that took place over a 2 year period.
 85,000 BCBS subscribers in the insured study
population had open access to MDs and DCs through
self-referral, and there were no limits applied to the
number of MD/DC visits allowed and no difference
in co-pays. Thius this study reveals what happens
when Chiropractic and Medical services compete on
a level playing field.
Chiropractic Cost-Effectiveness
 The researchers compared the costs of low back pain
care initiated by a DC with care initiated through a
MD or DO. They found that costs for the DC group
were 40% lower.
 Even after factoring in the severity of the conditions
with which patients presented, costs when a DC
initiated care were 20% lower than if a MD/DO
initiated care.
Who does Manipulation?
 Osteopaths are trained to do manipulation
 Only a small percentage do OMM
 Chiropractors are trained to do manipulation
 Most DCs do some form of manipulation
 Physical Therapists are trained to do manipulation
 Are now PhDs wanting more indivdual practice rights
 Massage Therapists-some do types of manipulation
 Others such as DOM, Naturopaths and Homeopaths have
manipulation traiing
How long does it take to do OMM?
 It takes anywhere from 1 minute to 30-40 mins
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depending on the treatment, method and extent.
HVLA is usually fairly quick
Strain-counterstrain usually takes 1 to 3 mins per
area
Cranial usually takes 5-10 mins depending on
findings and areas
Visceral takes about 5 min
How We Feel with Insurance Companies
TART Documentation
 T: Tissue texture change; stability, laxity,effusions,
tone
 A: Asymmetry; misalignment,crepitation,defects,
masses
 R: ROM; contracture, ease of movement
 T: Tenderness; pain, discomfort
OMT Documentation
1. Perform and document a thorough history and
examination.
2.Determine, perform and document theraputic and
diagnostic intervention.
3. Put Somatic Dysfunction and the OMT Code first
on encounter forms "Somatic Dysfunction as noted
above" in your dictation.
4. List secondary diagnosis on encounter forms and
in dictation.
5. Use the -25 Modifier on the E&M Code for your
secondary diagnosis.
OMT Documentation
 When documenting OMT, use the documentation
guidelines three key components of history, examination
and medical decision making (MDM).
 The history should have a chief complaint, history of
present illness, review of systems and a past medical,
family and/or social history.
 Your physical examination would include your
musculoskeletal structural examination and any germane
body area or organ systems. The history and physical
examination should contain information germane to the
complaint or be part of a workup to rule out specific
pathology. One should not add components to the history
or physical simply to enhance the documentation.
OMT Documentation
 25 Modifier
 Modifiers are designed to better describe a code or
how that code is being used in conjunction with
another code or modifier. Typically it is used for two
unrelated problems such as a treating a UTI at the
time of an excisional biopsy.
OMT Documentation
 With OMT, the diagnosis somatic dysfunction is
listed first with the correlating ICD code(s) and CPT
code without a modifier. The second, third and/or
fourth diagnoses are listed and these justify or create
medical necessity for the E&M service billed (your
consult, in or outpatient codes). The E&M code gets
a modifier here just like the UTI example, but the
E&M code need not be for a separate problem
and can in fact be what prompted the OMT.
My Documentation
Cervical
Exam Manipulation done to this area, Lesions found were corrected. Cervical
Tissue Tissue tenderness tightness, Boggy on the right. ROM slightly decreased.
Cranial
Exam Cranial dysfunctions were evaluated and corrected as needed. Decreased motion
noted. Feels Decreased motion Tight on the right.
Ilium
Exam Iliac dysfunctions were evaluated and corrected as needed.. Findings Right Ilium
Rotated Posterior.
Lumbar
Exam lumbar dysfunctions were evaluated and corrected as needed.
Findings Paravertebral tightness was noted. Feels tenderness to palpation with Decrease
Motion. Lordos is Normal.
Sacrum
Exam Sacral dysfunctions were evaluated and corrected as needed. Sacral
dysfunction Abnormal findings were noted Paravertebral Tightness Bilaterally. ROM Stuck in
Extention. Feels Tender with Decreased motion.
Thoracic
Exam Thoracic Dysfunctions were evaluated and corrected as needed.. thoracic Thoracic
tightness noted really tight between shoulder blades. Muscle Involvement Rhomboids
Thoracic paravertebrals tightness is noted.
Extremities
Right wrist Manipulation done. Shoulder Bilaterally, Tenderness to
palpation. Hip decreased ROM, Pain with palpation. Articulatory technique was done
What are the Benefits of Manipulation?
 It helps patients by:
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Reducing pain and suffering
Returning them to normal state quicker
Retuning them to work faster
Increases function
Reducing medication needs
 It helps you by:
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Getting results, which makes you look better
Increasing your referral base because you get results
Increases your reimbursement and bottom line
Helping you feel more comfortable with each OMT done
Payment for OMT
 98925 (1-2)
 BC $51.83
 98925
 Medicare $29.13
 98926 (3-4)
 BC $71.44
 98926
 Medicare $39.12
 98927 (5-6)
 BC $93.86
 98927
 Medicare $50.99
 98928 (7-8)
 BC $109.28
 98928
 Medicare $59.55
 98929 (9-10)
 BC $124.84
 98929
 Medicare $68.69
Top 10 Reasons to do OMM
 1. Patients like it and you can make more money!
 2. Results can be amazing!
 3. You can get a workout!
 4. You get paid to beat up on people!
 5. You are called a masochist!
 6. You can hurt patients and they ask to come back!
 7. You get to hear your patients say, “You enjoy hurting
me, don’t you!” (because they see the smile on your face)
 8. Not everyone can do this!
 9. You can hurt people and get away with it!
 10. People seek you out!
The End is Near
You are an OSTEOPATH!
 Think like an Osteopath!
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Rule out the serious causes and then fix the problem
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To be a good Osteopath you need to “think” with your hands
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Trust what you feel
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There is a treatment for most everyone, soft tissue techniques
work well, you don’t have to hear bones crunch to get results!
Questions?
References
^ a b c d e f Zuger A. Scorned No More, Osteopathy Is on the Rise. New York Times. 17
Feb 1998.
^ a b Gevitz, N. (1 April 1994). "'Parallel and distinctive': the philosophic pathway for
reform in osteopathic medical education" (Free full text). The Journal of the American
Osteopathic Association 94 (4): 328–332. ISSN 0098-6151. PMID 8027001.
http://www.jaoa.org/cgi/pmidlookup?view=long&pmid=8027001. edit
^ Lloyd, Janice.Doctor shortage looms as primary care loses its pull. USA Today. 18
Aug 2009. Accessed 08 Sept 2009.
^ a b c d Shannon, S.; Teitelbaum, H. (Jun 2009). "The status and future of osteopathic
medical education in the United States". Academic medicine : journal of the
Association of American Medical Colleges 84 (6): 707–711.
doi:10.1097/ACM.0b013e3181a43be8. ISSN 1040-2446. PMID 19474542. edit
^ a b c Gevitz, N. (Jun 2009). "The transformation of osteopathic medical education".
Academic medicine : journal of the Association of American Medical Colleges 84 (6):
701–706. doi:10.1097/ACM.0b013e3181a4049e. ISSN 1040-2446.
PMID 19474540. edit
^ a b Cohen, J. (Jun 2009). "The separate osteopathic medical education pathway: isn't
it time we got our acts together? Counterpoint". Academic medicine : journal of the
Association of American Medical Colleges 84 (6): 696.
doi:10.1097/ACM.0b013e3181a3ddaa. ISSN 1040-2446. PMID 19474536. edit
References
^ "AAMC Medical Schools". Association of American Medical Colleges.
http://www.aamc.org/medicalschools.htm. Retrieved 2006-12-13.
^ Salsberg, E.; Grover (Sep 2006). "Physician workforce shortages: implications
and issues for academic health centers and policymakers". Academic medicine :
journal of the Association of American Medical Colleges 81 (9): 782–787.
doi:10.1097/00001888-200609000-00003. ISSN 1040-2446.
PMID 16936479. edit
^ Geographic Map of Colleges of Osteopathic Medicine. AACOM.
^ About the AOA. American Osteopathic Association. Accessed March 2008.
^ How many DOs are there in the United States?
Journal of Manipulative Physiol Ther 2010(Nov); 33(9): 640-643