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PT Dilemma: Different Insurance Types – Addressed

September 21, 2010 • Business • Larry Benz

I posed the following scenario a few days ago for the vast readership of this blog:

3 patients are seen back to back by the same therapist for rotator cuff tendinitis in a private practice.  One patient is 65 years old and has medicare. The second patients is 50 years old and has private insurance which pays roughly $95 per visit for up to 30 visits. The third patient is 45 years old and has a high-deductible insurance and a $35 copay and your company contracts with his insurance company for a max of $50 per visit.  For the sake of discussion, there are no comorbidities or underlying factors – each patient has essentially the same diagnosis and will require identical interventions.

Questions:

1. If you are the PT, are you concerned at all with their health insurance coverage and benefits?  Would you treat them differently based on those differences with respect to time in clinic, # visits, interventions?

2. Same ques as #1 but you are the owner of the clinic?

3. Would or should a brand new PT treat the patients differently?

4. Does it make a difference if the PT is an orthopedic certified specialist?

5. Does the scenario change if the patient is not at a private practice clinic but a hospital outpatient clinic or center (provider based reimbursement)?

I can tell by the answers in the comments as well as the volume of email (several who subscribe by email simply wrote in their responses in a reply-very clever) that this is a very real scenario.  Let me take my stab at answering by doing something I like to do-tell stories.

Imagine these 3 rotator cuff patients all happen to be at the same ballgame watching junior’s soccer game. They get to talking about physical therapy.  The medicare patient explains how many visits he went to PT, what they did, and how it was mostly covered by his medicare.  He says he went in for about 9 visits and spent about 38 minutes with a PT each visit and is now on his own to do some kind of elastic band gizmo cause his medicare ran out -thinks both medicare and gizmo are a crock but he really liked the cute therapist but also thinks he was only sent there because the PT was in the same office as the doc. The second patient (the one with the good private insurance) spent an hour with a variety of “therapists” for 15 visits.  Says his shoulder is in great shape and says he has already returned to fly fishing.  The third patient (hi deductible and co-pay and max $50 visit) says that he didn’t get anything out of physical therapy as he was only given 3 visits, about 30 minutes with a PT and several sheets of paper with HEP written at top and his doctor told him to quite because PT was too expensive and that he can do it at home. Says that he will never go back to PT.

I am sure that many of you hear these same kinds of things all the time.  It is as clear to me that PT’s are as inconsistent in treatment approaches as they are in their approach to insurance types.  This inconsistency drives the commoditization of our profession, diminishes our value, and unfortunately has contributed to ratcheting down pricing.

Comments to the blog post were insightful-“we have the obligation to understand and respect the patient’s financial situation” and interesting “……lose customer loyalty if customers have “sticker shock” and at least 2 PT’s had quite opposite experiences at hospitals vs. private clinics (ouch, yet more inconsistency!).  Many are consistent with my thoughts.  While there are no “wrong” answers per se, it does generate a lot of thoughts and options.

Here are a few of my takes:

1. I abhor the whole construct of equating PT with home exercise programs.  When we claim to “accelerate” the rehab process because somebody doesn’t have the means for the real thing and therefore give them a HEP as a “substitute” we do a lot more damage than we do good. If anything, the evidence is pretty damaging to home exercise programs as a substitute. How can we call ourselves “evidence based” and then fall into this trap of HEP’s?  No wonder docs tell patients they can just do it at home.  Here is the gut check-what are you doing to the patient on every visit that they can’t do “at home”?  If more PT’s asked themselves that simple question, we can drive the value of what we do considerably to all stakeholders.  This doesn’t mean that only interventions that can’t be done at home be done in a PT clinic as it is the combination of items that make for the best outcome but it does mean that we owe value and expertise on every visit.  My personal bias is that we don’t exercise patients enough in the clinic and rely on totally on their home compliance to do this-few medical professionals would totally entrust their outcomes to chance like this.  I am further convinced that all stakeholders (patients, insurance companies, and PT’s) suffer from something that I call the “chiropractor bias”. It is the notion that left to chance, we will keep patients coming in forever.  Our profession has become victim of this bias by trying to “limbo lower” one another and claiming that our patients get better in some ridiculously low visit number.  I still remember the complaints we had against blue cross years ago when after 12 visits they made us get a precert.  The pendulum has now swung to such a low number that we might just become the Shaker’s of the medical world and eliminate ourselves in favor of a HEP handout and a DVD.

2. Whether it is a financial aid office at a college or registration at a hospital, we have to respect the detail and competencies of this process.  Private clinics typically do a terrible job of providing appropriate counseling to the patient of their responsibilities, limits, etc. This should also include that patients understand that there might be a legit discrepancy between what their insurance covers and what the therapist believes is the best plan of care. If that is the case (and this also resolves my points above), then the patient should have options for paying or refusing with the understanding that imposed restrictions will impair outcome.  By the same token, databases of information on the patient’s diagnosis should be used to provide the patient
with a “best guess” of what the total therapy costs are (approx visits, cost per visit, etc).  I think patients deserve this information as part of the initial processing.  While I agree with the comments that hospital PT’s generally aren’t as oriented to payment restrictions as private practice, it is often because of the extensive processing that they do on the front end.

3. I am not so sure about specialization-have completely mixed thoughts here.  In the medical model, it is very difficult to practice without board certification.  It is an option in PT and a foundation of specialization was always that it did not imply any payment differential.  I think this concept needs to be re-visited at least for the sake of discussion. I pay other professions a differentiating fee for going the extra mile.  Would such a difference drive more than the current approx 5% of PT’s towards specialization?  I do know that the military’s higher professional pay has driven their percents way above most other work environments.   Besides board certification, you also have residency training, Fellowship, and Fellows by AAOMPT and others.  I can only tell you that when I have low back pain, I seek a specialist PT-preferably a manual therapist Fellow!

4.  I wouldn’t suspect many readers of this blog to take contracts at $50 per visit.  Unfortunately, there are far too many who have fallen into that trap and in an attempt to “make the margin” provide too little care and too many home exercise programs (see #1 above).

5. The setting between hospital and private practice while it shouldn’t make a difference, it does simply because there might be reimbursement differences that favor the hospital. Again, the great equalizer is adequate processing of the patient, providing estimates, getting them to acknowledge that their insurance might not pay for the best outcome and then letting them choose to pay outside of their insurance or not.  I believe this equalizer also applies to all PT’s in an outpatient setting-even new grads.

Imagine if all 3 of the patients were given adequate information prior to initiation of their first visit to their PT.  If they elected to only go for what their insurance covers, at least they could then understand that their outcome could be compromised by their choice and not what the PT was left to determine solely based on their insurance.  I am quite confident that our profession would be much better off and home exercise programs would no longer be confused or equated to physical therapy.

Expect to see Weekend Dilemma as part of a regular irregular feature of this blog and thanks for your the dialog.

Thoughts?

[email protected]

Larry Benz

Dr. Larry Benz, DPT, OCS, MBA, MAPP, is the Executive Chairman of Confluent Health. He is nationally recognized for his expertise in private practice physical therapy and occupational medicine. Dr. Benz’s current areas of interest include conducting research and integrating empathy, compassion, and positive psychology interventions within physical therapy. He released a book on September...

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