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Thread: Strength Training in Primary Care

  1. #11
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    Quote Originally Posted by Mark Rippetoe View Post
    And when we've had the studies, what have they produced? Saturated fat causes heart disease, dietary cholesterol causes hypercholesterolemia, salt causes hypertension, tendonitis cannot be corrected without surgery, squats are bad for the knees, etc. Strength training will be a part of primary care when physicians start lifting weights, and not until then. You guys better get busy with your peers.
    I don't think any good doctor will say that thing, anyway - not mine. What he should and would say is: the animal fat can rise your LDL, thus contributing to developing of heart disease; alimentary cholesterol will only have a small effect on the levels of cholesterol in your blood; salt MAY raise BP in some individuals. These all are risk factors, not the causes.
    Regarding physicians lifting weight - can't see it happening in doctors older than 50+. You're old now, just take some good walk.

  2. #12
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    I'm a Urologist in the States and agree that it gets complicated to think about incorporating strength training into ones personal practice. I'm lucky enough to have a SS coach that I'm able to refer patients to. I provide my patients with a letter of medical necessity which allows them to use their HSA, HRA or FSA funds to cover their training costs. Unfortunately I've yet to see any plans that cover training directly.

  3. #13
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    Quote Originally Posted by Lithotomist View Post
    I'm a Urologist in the States and agree that it gets complicated to think about incorporating strength training into ones personal practice. I'm lucky enough to have a SS coach that I'm able to refer patients to. I provide my patients with a letter of medical necessity which allows them to use their HSA, HRA or FSA funds to cover their training costs. Unfortunately I've yet to see any plans that cover training directly.
    It might be unfortunate. Maybe it would be good to have that kind of coverage.

    But...

    I've often had occasion to reflect on this...and I'm not 100% sure it's a bad thing that we don't have such coverage. As a hospital-based physician, I was insulated for many years from direct issues of billing and reimbursement. I showed up for work, saw my patients, documented, and got a paycheck for the hours I worked in The Pit. Billing? What's that?

    Then I joined our group's Board of Directors. What an eye-opener.

    I own a Starting Strength gym now, and it's always busy, at or near capacity all the time...and it's a cash business. I have some clients who are financially strapped, and I work with them, because I really love to get people strong, and if they're willing to do the work I really want to help them. I've done a fair of pro-bono work. I'm not saying this to brag, but to point out the flexibility provided by this business model. When it's your shop, you get to do shit like that at your discretion. It's a beautiful way to do business.

    So, as an S&C professional, I'm pretty sure I don't want to be involved with third-party payors--government or corporate (the former over-regulate and over-prosecute; the latter are just fucking crooks and cheats and monsters).

    Look, exercise medicine is just that, but as I've pointed out many times, it has several properties that make it a unique medicine--inverted dosing, active self-administration rather than passive receipt, reducing the need for other medicines, and so on. Another unique property is its cost. Compared to most allopathic medical interventions, exercise medicine is really cheap, even if you go platinum with in-person training with an SSC. It's even cheaper when you consider the long-term impacts on health....personally and globally.

    And then there are the intangible effects--beneficial on balance, I think--of putting up some of your own $ for this particularly powerful and cost-effective medicine. That's a big topic in itself, touching on issues of motivation, compliance, responsibility, etc.

    None of which obviates the outrage that most primary care physicians are not actually prescribing exercise medicine, or prescribing it improperly. Our discharge instruction system in the ER has no option to produce written instructions to the effect that "you should really get up off your fat, lazy ass and go for a walk every day...it'll make you feel better than these toxic pills we just prescribed." In 25 years of medical practice, I've seen exactly one exercise prescription....the one a new client brought to me a couple of months ago ("strength training twice a week for 6 months").

    So yeah...it's all fucked up. But I'm not convinced that coverage is the answer.

  4. #14
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    Quote Originally Posted by Lithotomist View Post
    I'm a Urologist in the States and agree that it gets complicated to think about incorporating strength training into ones personal practice. I'm lucky enough to have a SS coach that I'm able to refer patients to. I provide my patients with a letter of medical necessity which allows them to use their HSA, HRA or FSA funds to cover their training costs. Unfortunately I've yet to see any plans that cover training directly.
    Forgive me for my ignorance but how does a Urologist justify recommending strength training when dealing with patients with urology problems? Or do you see other patients as a GP?

  5. #15
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    Quote Originally Posted by Jonathon Sullivan View Post
    So, as an S&C professional, I'm pretty sure I don't want to be involved with third-party payors--government or corporate (the former over-regulate and over-prosecute; the latter are just fucking crooks and cheats and monsters).

    Look, exercise medicine is just that, but as I've pointed out many times, it has several properties that make it a unique medicine--inverted dosing, active self-administration rather than passive receipt, reducing the need for other medicines, and so on. Another unique property is its cost. Compared to most allopathic medical interventions, exercise medicine is really cheap, even if you go platinum with in-person training with an SSC. It's even cheaper when you consider the long-term impacts on health....personally and globally.

    And then there are the intangible effects--beneficial on balance, I think--of putting up some of your own $ for this particularly powerful and cost-effective medicine. That's a big topic in itself, touching on issues of motivation, compliance, responsibility, etc.
    I would close my gym before I would involve myself with 3rd-party pay.

  6. #16
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    Quote Originally Posted by Jonathon Sullivan View Post
    None of which obviates the outrage that most primary care physicians are not actually prescribing exercise medicine, or prescribing it improperly. Our discharge instruction system in the ER has no option to produce written instructions to the effect that "you should really get up off your fat, lazy ass and go for a walk every day...it'll make you feel better than these toxic pills we just prescribed." In 25 years of medical practice, I've seen exactly one exercise prescription....the one a new client brought to me a couple of months ago ("strength training twice a week for 6 months").
    As a Belgoonian, it's really weird to hear you say that. Whenever I went to see the MD during my teenage years, the doctor would always enquire upon my weight and level of activity, urging me to lose weight and move around more. It was never really helpful advice, corroborating what you said about improper prescriptions, but they did take issue with my fluffy detrained novice body. I believe you when you say doctors don't share this practice like they do in Europe/Belgium, a fact that remains both strange and hard for me to swallow.

    Oh! A friend of mine and training partner went to a "knee specialist" the other day (not making that up). The guy told him "squat less/less deep" and advised he get imaging done. I told him previously not to waste his time and money (eh, cheap in the EU, but time isn't), but he went anyway. I told him I wouldn't get the imaging done if it was me, just widen the squat stance. This wasn't his first run-in with a specialist, so he wasn't expecting the world. Later in the same workout, he came up to me and said "think about it: a knee specialist told me to squat less deep...", lingering on his pause and stressing the term "knee specialist" when he said it. I just nodded in his face with the look of acceptance and foreknowledge on mine. I doubt he'll be going to any more specialists after this. The guy told him his patella is loose, can you fucking believe it?

  7. #17
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    Quote Originally Posted by Scaldrew View Post
    As a Belgoonian, it's really weird to hear you say that. Whenever I went to see the MD during my teenage years, the doctor would always enquire upon my weight and level of activity, urging me to lose weight and move around more. It was never really helpful advice, corroborating what you said about improper prescriptions, but they did take issue with my fluffy detrained novice body. I believe you when you say doctors don't share this practice like they do in Europe/Belgium, a fact that remains both strange and hard for me to swallow.

    Oh! A friend of mine and training partner went to a "knee specialist" the other day (not making that up). The guy told him "squat less/less deep" and advised he get imaging done. I told him previously not to waste his time and money (eh, cheap in the EU, but time isn't), but he went anyway. I told him I wouldn't get the imaging done if it was me, just widen the squat stance. This wasn't his first run-in with a specialist, so he wasn't expecting the world. Later in the same workout, he came up to me and said "think about it: a knee specialist told me to squat less deep...", lingering on his pause and stressing the term "knee specialist" when he said it. I just nodded in his face with the look of acceptance and foreknowledge on mine. I doubt he'll be going to any more specialists after this. The guy told him his patella is loose, can you fucking believe it?
    This kind of shit is coming to America. Medicare is starting to enforce their "MIPS" measures. If docs don't badger their patients about BMI at every visit, pay will be docked 9%. This is what happens when you put your government in charge of your health care.

  8. #18
    Brodie Butland is offline Starting Strength Coach
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    Quote Originally Posted by Mark Rippetoe View Post
    I would close my gym before I would involve myself with 3rd-party pay.
    And the funny thing is, this was the stated end goal of the USREPS/CREP personal trainer licensure push. These folks WANTED insurance to get involved.

  9. #19
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    Quote Originally Posted by Pluripotent View Post
    This kind of shit is coming to America. Medicare is starting to enforce their "MIPS" measures. If docs don't badger their patients about BMI at every visit, pay will be docked 9%. This is what happens when you put your government in charge of your health care.
    From some quick browsing, Medicare has a set of performance criteria and adjusts what it pays under Part B based on adherence to those criteria. Amounts increase from plus or minus 4% for year to plus or minus 9% in 2020 based on all criteria (possibility of higher bonuses), but all intended to by budget neutral. 10 FAQs about the Merit-Based Incentive Payment System (MIPS) | SA Ignite

    They have a variety of quality measures and it appears doctors can choose a small number of criteria from a long list, if I'm reading Merit-based Incentive Payment System (MIPS) Overview - Quality Payment Program and MIPS Quality Measures - Quality Payment Program correctly. I haven't found anything that specifically requires doctors to "badger their patients about BMI at every visit".

    It doesn't seem that much of an overreach for a payor to have criteria for making payment. This doesn't appear to affect payments from patients, insurance companies, etc.

    I'm just relying on some quick browsing. What did I miss?

  10. #20
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    Quote Originally Posted by Elephant View Post
    From some quick browsing, Medicare has a set of performance criteria and adjusts what it pays under Part B based on adherence to those criteria. Amounts increase from plus or minus 4% for year to plus or minus 9% in 2020 based on all criteria (possibility of higher bonuses), but all intended to by budget neutral. 10 FAQs about the Merit-Based Incentive Payment System (MIPS) | SA Ignite

    They have a variety of quality measures and it appears doctors can choose a small number of criteria from a long list, if I'm reading Merit-based Incentive Payment System (MIPS) Overview - Quality Payment Program and MIPS Quality Measures - Quality Payment Program correctly. I haven't found anything that specifically requires doctors to "badger their patients about BMI at every visit".

    It doesn't seem that much of an overreach for a payor to have criteria for making payment. This doesn't appear to affect payments from patients, insurance companies, etc.

    I'm just relying on some quick browsing. What did I miss?
    My hospital group is currently pushing a MIPS drive, and no, I don't get to choose which measures I follow. They have chosen about 5 that they want to see in a note somewhere during the admission, and if the patient gets handed off, the new provider needs to do it again. Many of these measures are best left to the outpatient setting, for instance, I'm supposed to document their blood pressure and document that I've talked to them about lowering it. Blood pressure is pretty unreliable in the inpatient setting, and often the blood pressure is high because patients are sick and in pain and stressed out. Often not a great time to diagnose essential hypertension or start new meds.

    And yes, I'm supposed to badger them about their BMI on each visit and each change of provider in that visit. The whole MIPS documentation is longer than the actual note and takes a long time to complete while adding no useful information except as a way to dock pay if it isn't there and in the proper way.

    And FYI, Medicare is the largest payer and most insurances follow their lead, so it affects everything.

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