by Kaley Capitano, DO
The last few months of residency are a joyous time in medical education. The culmination of 7-10 years of post-graduate training, sitting on the precipice of full independence and promises of financial healing. As I walked into the examination room of a patient I’ve been managing regularly since my intern year, I felt great. But when I explained their transition of care as I exited the practice, my patient’s shocked statement caught me off guard.
“Wait, you’re a doctor?! I thought you were the doctor’s assistant or something. Isn’t that what a D.O. is?”
My heart sank.
To be six weeks away from independent medical practice, hearing this not only left me feeling undervalued and a novice in comparison to my equals it also stung as an injustice to myself and my peers. The patient had been through dozens of scheduled appointments and interactions with both myself and support staff referring to me as ‘doctor’. How could my position escape them?
It’s well established that gender respect is an issue in the medical field.
As a young female in medicine, I am almost assuredly referred to or thought of as anything BUT a doctor when I am first introduced to a patient. ‘Nurse’, ‘Tech’, ‘MA’, ‘Assistant’. Even after a kind but firm correction, some patients continue to negate my expertise using pre-conceived biases based on my appearance.
What I had not considered, however, is that some may see “D.O.” after my name and do the same.
I’m not angry with this patient. It was an innocent, uninformed mistake. However, our interaction led me down a reflective path at the subtle pervasiveness in which our own medical infrastructure devalues and disincentivizes the osteopathic skillset. Given that the practice of Osteopathy was founded in 1874, there is really no excuse for it being so candidly unknown and/or disregarded (1).
So why has the majority of the population never heard of a D.O.?
One likely reason is that D.O.s are in every medical specialty, the same as our M.D. counterparts. The distinction between us rests in the practical application of D.O. specialty techniques. If not actively engaging in Osteopathic Manipulative Treatment (OMT), D.O.s and their M.D. colleagues are indistinguishable – and some reports indicate that 60-80% of D.O.s do not practice OMT (2). Therefore, without having experienced OMT by a D.O., most patients assume all doctors are M.D.s, and the D.O. distinction is simply a new and lesser achievement. Nothing could be further from the truth.
Aside from lessening awareness of the D.O. degree, chronic underutilization of OMT results in lost potential for improved patient outcomes and reduced healthcare costs. OMT works.
A 2009 retrospective analysis of the cost of treating patients with migraines between allopathic and osteopathic clinics in Florida showed that the average cost per patient visit was approximately 50% less at the osteopathic clinic than at the allopathic clinic ($195.63 vs $363.84, respectively; P<.001). This observed difference was attributed to the lower average number of medications prescribed at the osteopathic clinic (0.696 vs 1.285 at the allopathic clinic (P<.001)) as a result of OMT (4).
A 2010 randomized controlled trial assessing outcomes in patients hospitalized with pneumonia across 7 community hospitals displayed a statistically significant decrease in duration of intravenous antibiotics, length of stay, as well as death or respiratory failure in the OMT group versus the conventional care only group (5).
A 2005 meta-analysis on low back pain across both the United States and United Kingdom demonstrated significant pain reduction in trials of OMT vs active treatment or placebo control and OMT vs no treatment control (P = .001). Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up (6). One can then extrapolate reduced analgesic utilization, including the risk-riddled opioid class which many low back pain patients invariably seem to present to our practices on.
Personally, I have witnessed the impact OMT has on reducing various musculoskeletal limitations and pain. I have observed immediate increased cervical range of motion following OMT. I have watched sciatica disappear, frozen shoulders loosen, and headache frequencies dissipate.
OMT has also had a significant impact on my chronic pain patients. “FK” is a 27-year-old legally disabled patient with Chronic Regional Pain Syndrome, Idiopathic Intracranial Hypertension, and various sensory nerve deficits following a trauma sustained at high speeds many years ago. Recently, when I notified her of my upcoming departure for fellowship training, she instantly burst into tears. Unbeknownst to me, her neurologist and pain clinic specialist had both recently told her they had maxed out every modality they could think of to control her debilitating pain. She had left those visits feeling hopeless. She went on to tell me that our monthly OMT sessions were the only thing that kept her somewhat functional, usually buying her about two weeks of reduced pain.
She was able to join family dinners at the table, drive herself short distances instead of relying on her mother, and experienced two weeks of increased independent ADLs that a 27-year-old shouldn’t have to think about. The panic she displayed at the upcoming loss of these treatments (ultimately due to the general the lack of OMT access in our community) broke my heart. It also impassioned me to ask the question:
Why aren’t more primary care D.O.s practicing osteopathic medicine?
A 2021 study surveying 10,000 osteopathic physicians nationally cited impactful barriers to OMT as due to lack of time, lack of reimbursement, lack of institutional/practice support, and lack of confidence/proficiency (2). But I ask, is time really a barrier?
There are certainly some techniques (such as myofascial release) that are slow to perform and help more effectively treat deeper musculoskeletal layers; a type of warm-up treatment typically done in conjunction with others. This can be objectively time consuming. And to comprehensively treat an area of concern, I have found 40-minute appointments to be ideal. That being said, one can reasonably treat pelvis, sacrum, and the lumbar spine as interconnected structures for, say, low back pain, within the 20-30-minute standard patient visit. And when done in isolation, it takes 1 minute to reset a pelvis, realign a vertebra, or lengthen a piriformis. These things can easily be thrown onto the end of a patient visit when indicated. Is the barrier actually time? Or is time simply a red herring for what it represents: revenue.
Revenue is often the crux supporting underlying decision-making policies that determine treatment avenues.
In the United States revenue is often the supreme marker of value in relation to all other modalities. Sadly, American healthcare is no different. Insurance companies led by individuals without a medical degree dictate which medications physicians can offer their patients. Big medical conglomerates across the nation push incessantly for increased clinical production. In a Capitalistic society that has converted the value of a human being’s health into a dollar amount to be captured, physicians are paid by the number of patients they see in a day.
As a result, standard visit times are pressured to shorten. Any visit type that reimburses less than the standard is ultimately devalued and unsupported within systemic medical infrastructures.
Given general unfamiliarity with how to approach reimbursement, OMT frequently falls into this category. In that same 2020 survey of osteopaths nationally, the writers conclude that “barriers to [the use of OMT] appear to be related to the difficulty that most physicians have with successfully integrating OMT into the country’s insurance-based system of healthcare delivery.” (2)
But there is hope.
Standard E/M reimbursement for a 99214 (most 20-30-minute visits) is $109. Standard CPT reimbursement for a 98926 (3-4 body regions treated with OMT) or a 98925 (1-2 body regions treated) is $39 and $26, respectively. A frequent mistake Osteopaths make is billing for the treatment itself, 98925 or 98926, and nothing else. This is appropriate if you evaluated the dysfunction at a prior visit, the patient is returning solely for OMT, and you start manipulations immediately without any further evaluation. And in this setting, it’s not hard to imagine why $26-39 vs. $109 reimbursed for a standard patient visit leads to systemic devaluation. Particularly when OMT requires physical hands-on effort by the physician. I argue, however, that this structure is rarely the occurrence, even during even isolated OMT visits. My Osteopathic colleagues simply aren’t billing appropriately for what they are already doing.
It takes minimal time to do a quick assessment of the body region of concern with appropriate documentation, resulting in an additional E/M code of 99214. We all do this anyway – evaluating new or known dysfunctions prior to treatment (I urge you to read, “Coding Level-IV Visits without Fear” at www.aafp.org/fpm). When billed appropriately, most OMT visits reimburse for $109 (99214) + $39 (98926) = $148 compared to the standard 99214 $109 reimbursement. And within the same visit time. Even quickly evaluating and lengthening a piriformis in which OMT takes 1 minute of the visit allowance can gain an additional $26 of reimbursement (98925) equaling $135.
Implementing OMT is neither an issue of time nor is it a revenue loser.
It leads to higher reimbursement than a standard visit. For those who find higher efficacy from a slightly more comprehensive approach involving increased fascial body work, a 40-minute visit reimbursed solely based on time still gains approximately $148. However, a 40-minute visit reimbursing for the same amount as a 20-30-minute visit requires institutional support.
And Institutional support is perhaps the greatest barrier of all.
First, there are the small things: special EMR-encoded visit types so that the individual D.O. can choose to balance their clinic day with specifically saved slots for OMT or perhaps a cap on the total number of OMT visits available per day. Secondly, clinics need to provide the appropriate OMT examination tables.
There is also the larger barrier. Does your presiding medical group or conglomerate support extended 40-minute visit times for optimal patient care? For this, I applaud my medical residency. They allowed me to practice 40-minute OMT visits throughout my training, which directly benefited the health of our community. Keep in mind that 5-10 minutes is almost always lost to patient rooming tasks and evaluation/discussion with the patient. Allowing 30-minutes for OMT permitted me to appropriately treat interrelated structures using a multitude of techniques.
This kind of support during the beginning stages of independence has led to increased confidence, refined skill, and more expedient practice. After three years of utilizing OMT, I can now treat in 15-20 minutes what used to take me 30-40. Just like that, I have the confidence and skill to complete a 99214+98926 within the standard patient visit time.
As a medical field, we must increase the optics of the D.O. profession as a skilled and equal partner to the M.D. by promoting the use of OMT techniques. Internal pressure to reduce OMT utilization due to lack of perceived value-for-effort has resulted in physicians who no longer trust their proficiency and eventually stop performing OMT altogether. Each time this happens, population health suffers the loss of a meaningful skill to combat pain and dysfunction and the D.O. further recedes from notable distinction – not to mention lost revenue for medical practices.
When D.O.s are fully supported by reimbursement policies, we are motivated to continue to practice, our confidence bolsters, and our skills streamline. As a result, patients flourish. Institutions that have support D.O.s in their pursuit of integrating OMT into clinical practice experience both increased revenue and coveted boosts to patient satisfaction.
Allowing those 40-minute OMT visits in the initial training period is a beneficial and critical step to patient care and our profession in general. Continuing to lobby our policy makers, promoting our osteopathic colleagues, and fighting to put patient care at the center of value results in a happier, healthier population. OMT can be a life-changing modality.
We simply need to value and promote what makes D.O.s remarkable in the first place.
Kaley Capitano, DO is a Family Medicine resident at The University of Utah. She completed her medical training at Midwestern University in Phoenix Arizona and graduated with a degree in Biological Sciences from the University of California, Davis. Her professional interests include Sports Medicine, LQBTQ+ care, and in-office procedures. In her spare time she enjoys an array of outdoor sports, curling up on the couch with a good sci-fi book, and spending time with her husband & rescue dog Jazzy.
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