As the Physio Moves Canada team prepares for the long drive from Ottawa up around the Great Lakes and into Winnipeg this weekend, we are learning about the Winnipeg Region Health Authority's decision to remove public funding for outpatient adult physiotherapy services, effectively meaning that the largest segment of the population who requires these services for their livelihood (working age adults) will very often find these services inaccessible. I'm referring in particular to the middle class, those who will not pass the 'means test' on income because they are not in the lowest income brackets, yet also struggle to get by on a monthly basis leaving very little left over for 1 or 2 physio visits per week at, say, $45-$90/visit (or up) depending on where you go and the level of service needed. This has been touted by WRHA as a cost saving measure, possibly saving the authority somewhere in the range of $1.5 - $3 million in the first year (of an apparent $83 million reduction target mandated by the province). This is bad, this is bad not only for the profession but for the Canadians that rely on physiotherapists for their pain and mobility management needs.
Physiotherapists are medically-trained rehabilitation experts for issues of mobility and non-pharmacological pain management. If we start with the second of those, non-pharm pain management, it is gob-smackingly shocking in our current opioid climate that WRHA should be restricting access to an alternative pain management approach. It would be over-reaching to say that we should expect to see an increase in opioid abuse as a result (far far over-reaching) BUT when the rest of the world is looking at ways to increase access to opioid alternatives, Manitoba appears to be heading in the wrong direction.
The mobility piece however may be the even more concerning issue but one that isn't currently as sexy as pain. If there's anything I've learned as we near half way through the Physio Moves Canada project, it's that mobility forms a critical component of the identity of Canadians. If your mobility is impaired, you may have difficulty working (and earning an income, so that you can now pay for physiotherapy... ugh), you may have difficulty looking after your family, maintaining your home, or living without depending on other people. All of these things have the potential to increase costs borne by the tax base, possibly through greater reliance on social support services, disability or unemployment insurance benefits, mental health services (I've become convinced of the intimate tie between independent mobility and mental well-being), and in what should be the most ironic twist in all of this - greater burden on public health services! We've already seen this in Ontario, where adult outpatient physiotherapy has been delisted from from the Ontario Health Insurance Plan (OHIP) since 2005. For those unable to access appropriate physiotherapy care, their only options are to look for less expensive (and less trained) alternative providers often meaning they are off work or otherwise disabled longer, or go to medical clinics and emergency departments for help and advice. So while the delisting from WRHA may indeed save let's say $2.5 million in the first years of their budget, it will very likely end up costing the authority overall much much more in chronic disease management, orthopedic surgeries, psychological and social counseling services, and primary care visits (to speak nothing of the burden on social assistance systems), all of which can be ameliorated by timely access to good quality physiotherapy care. Of course it's not as though the WRHA will see that link, and suddenly reinstate adult outpatient physio - it will be lost to the sands of time, and 5 years from now they will note that costs were not in fact reduced as expected, and some other service will be changed, cut, 'optimized' or even added, all of which could likely have been avoided in the first place.
And now we come to the title of this post. I'm continuing to hear from clinicians and clients that physiotherapy has a branding problem, and we also appear to have a problem supporting our national advocacy body. Now I'm not saying for sure that these are the driving forces behind this decision (the driving force can be more easily described as dollars and cents). But, why physio and OT are being cut, why not orthopedic surgery? I know right, that sounds insane. But why does it sound insane? There's an increasing tide of evidence to suggest that many common surgical procedures, especially for knees, backs, and shoulders, have no better outcomes than a good course of physiotherapy while being far more costly and risky. Yet can you imagine the outcry, from the Canadian Medical Association, consumer advocacy groups and the general public if something as hallowed as orthopedic surgery was suddenly something Manitoban's had to pay for? One wonders what would have to happen for physio and OT to trigger the same level of emotional response in the public as this bonkers idea of delisting orthopedic surgery. My suspicion, based on nothing more than my experiences engaging clinicians (and as a 20 year member of the profession myself) is that there are not enough members of the public, or even our colleagues in other professions, let alone health care administrators and policy makers, that adequately understand the value that physiotherapy brings. I keep saying this, and perhaps at some point I'll try it: if I were to ask members of the general public walking down the street what an orthopedic surgeon does and when you should see one, chances are most could provide a reasonable answer fairly easily. What a chiropractor does and when you should see one, again I suspect the answer would come easily (whether or not it's entirely accurate) because chiropractors as a profession have done a superb job claiming a key piece of the public mindshare. What about what a physiotherapist does, and when you should see one? I expect this to be a more difficult answer especially for those who have never engaged physio services. I could point to several reasons for this, and am hearing about many more from clinicians in Canada, but regardless of the mechanism(s), we appear to be suffering an identity crisis. Even within our own profession there appears to be far too much infighting - one only need to spend a half day on Twitter to see evidence of that. So when a group like the Winnipeg Regional Health Authority is looking for a professional body to cut from its funding model, which one is likely to cause the least outrage? How about this one over here that can't seem to even sort its own self out as to what it's meant to be?
Which brings me to the last point of this lengthy post, and that is this: only through strong and healthy national and provincial advocacy bodies can we earn back some of this highly valuable stakeholder mindshare. In Canada that means the Canadian and provincial Physiotherapy Association(s). Full disclosure here is needed: most of these bodies are providing some part of the funding for the Physio Moves Canada project, though are doing so at an arm's length meaning they have no control over the findings and publications. So take what I'm saying with the appropriate skepticism you should be giving to all such online 'talking forums' - but rest assured I am saying this from a position of someone who wants to retire in 25 years as a physiotherapist, meaning that there will need to be a physiotherapy from which to retire at that time: we need ALL Canadian physios to participate in the advancement of our profession, and currently the best way to do so (in my mind) is through supporting the CPA and its provincial branches. These are the people that are advocating and fighting on our behalf. Winnipeg is simply the latest consequence of a professional voice and brand that needs to be clearer, louder, and prouder - we need to come together.