Perhaps one of the biggest problems facing physical therapy is the absurd increases in the last few years of patient copays in private insurance plans.  We know historically that $10-20 copays do not increase or decrease utilization but there is no doubt $50 plus compels patients to stop.  In Kentucky, thru great leadership by our legislative committee and our super lobbyist, we decided to do something about it.

Yesterday, I had the priviledge of testifying to Kentucky Senate’s Banking and Insurance Committee regarding legislation that our KY PT Association has introduced in our State’s House and Senate.  My testimony in part:

I have been a licensed physical therapist in KY  for 25 years and represent the Kentucky Physical Therapy Association but more importantly represent the hundreds of patients who have had to self-discharge themselves from necessary physical therapy due to not being able to afford excessively high copays thrusted on them by their insurance company.

 Physical therapy is a mandatory benefit in KY.   While PT has grown in size, scope, and stature as a percentage of health care premium dollar it has actually gone down due to increases in high cost imaging, surgery, and pharmacy.   About 1-2% of the monthly payment for your health insurance is for physical therapy benefits.

 While it is reasonable to think that you have a physical therapy benefit through paying the high cost of insurance, the reality is that Insurance co’s have figured out a way to pass the entire cost of needed rehabilitation to patients and eliminate most of their responsibility and payments to physical therapy providers.

How did they do this?  In two strategic and purposeful ways.  The first is through dramatic increases in patient copays in last 5 years such that they are the majority and in some cases the entire allowable PT amount. The second way is by classifying PT in the same group of office visit copays for surgeons and others where the visit frequency is low.  For example, if you were to receive surgery, you would have a copay for that surgery. However, surgical coding is such that follow up visits are part of the surgeons global fee and there is no patient copay on those follow up visits. PT however requires a copay every visit and necessary rehabilitation requires multiple visits. Thus PT in most cases costs a patient more out of pocket than the surgery which necessitated the physical therapy need!  The high copay serves as significant financial disincentive which has kept many patients from full recovery and often causes downstream increase in disability, repeat surgery, and hi cost prescription drugs particularly pain pills.

 While an insurance company might attempt to argue that cost shifting may result with such legislation let me give you a different view.  By essentially eliminating PT as a mandated benefit it has caused greater profit margins while simultaneously eliminating a mandated and necessary benefit.  The reasons that PT are mandated in KY health plans is obvious.

 In physical therapy, we restore function and bring people back into the game of life.  By your passage of Senate Bill 112, you are restoring the faith and belief that Kentuckians have a real physical therapy benefit in their insurance plan.

An occupational therapist then testified and presented some great examples of how excessive copays halt needed PT and OT particularly in children.  Her stories hit home with the committee.

A lobbyist and her accompanying rep from some health plan association then presented in opposition to the bill what you would expect-you could have pulled the string yourself.  “slippery slope”, “can’t mess with health plan policy”, blah blah blah.  After that, lots of questions and debate from the Ky Senators began with one particularly viewing any such change must result in increased premiums.  I tried to debunk this “cost shifting” argument by pointing out that premiums are based on a multitude of factors and that the simple assumption it has to result in increased insurance premiums assumes that rates are a zero sum game and that insurance premiums don’t have a profit motive. There are primarily 4 ways that insurance companies deal with any medical utilization. The first is increasing premiums (and this is disproportionate to utilization and has a built in actuarial cushion a.k.a. profit). Second, is they put more burden on the insured (higher copay or higher deductible). The third is decrease allowable amounts to providers (I specifically mentioned that the major payors in KY’s allowable is less than medicare’s) and the 4th is policy (artificial limits of visits, code limits, calendar days, or putting us in “specialty” category for copays). The reality is that increased utilization of PT probably is an overall decrease in costs to both payors and patients. We have work comp data that shows rehab dollars are cheap-prevents disability, surgery, pain meds downstream.

At the end of the day though, the measure passed overwhelmingly with only one “no” vote. On to the Senate floor.  While our on floor discussion was important, frankly it pales to the work done by the legislative committee and even more importantly by the KPTA membership base whose grassroots efforts, mobilization, and communication with their political reps has a much greater impact-the credit goes to them. And that is where we need your help!  Anybody can call our Legislative Message Line at 1-800-372-7181 to voice support of Senate Bill 112 which would limit a patient’s out of pocket liability to 20% of the allowable amount. This bill is about patient advocacy-not payments to PTs or OTs.  Please feel free to give examples of patients who couldn’t complete PT due to excessive copays.  If you need any additional information or talking points, feel free to email me.

Let’s mobilize nationally and stop insurance companies from differentially picking on PT’s and OT’s thru excessive copays.  Thanks in advance for any help.

larry@physicaltherapist.com