Patients Have Different Insurance-Same Diagnosis. How do you treat them? #physicaltherapy

Last post, we provided a patient scenario and asked for comments. I can tell by the answers in 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 and for sake of reminder, here is the case:

Three 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 is the same patient but has medicare advantage. The third patient is 50 years old and has private insurance which pays roughly $95 per visit for up to 30 visits. The fourth 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 all require physical therapy 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 newly licensed 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 where there might be higher reimbursement (non medicare scenario)?

One thing remains from doing this several years ago-inconsistency. If the scenarios had nothing to do with insurance and just were about treating rotator cuff tendinitis, the approaches would be variable and that is always concerning. This inconsistency drives the commoditization of our profession, diminishes our value, and unfortunately has contributed to ratcheting down pricing because payors and CMS through Medpac years ago referred to physical therapy as the “black hole”-they don’t know what they are paying for or how long treatment will last as the only certainty is inconsistency. This goes to the value of clinical practice guidelines as published by the Academy of Orthopaedic PhysicalTherapy which would of course be a mandatory knowledge competency if we can get PT students to take boards halfway through their training as suggested in our previous post.

Comments directed to me via email and otherwise 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 thinking on the topic. 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. One kneejerk reaction to limited health insurance benefits: always gets the “home exercise” prescription earlier and more often. 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, uniqueness as a profession, 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-no 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 youtube video.

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 7% of PT’s towards specialization? I do know that the military’s higher professional pay has driven their specialty percentage way above most other work environments. Besides board certification, you also have residency training, Fellowship, and specialty certification. I can only tell you that when I have low back pain, I seek a specialist PT-preferably a manual therapist Fellow who also has pain neuroscience (PNE) training.

4. I wouldn’t suspect many subscribers to take contracts at $50 per visit. Unfortunately, there are far too many who have fallen into that trap and in an attempt to have some margin provide too little care and too many home exercise programs (see #1 above) when reimbursement approaches that level. Medicare Advantage patients who arguably need PT the most, will have the least access because their payments are below cost to providers. Unrelated but related, why do the Medicare Advantage players complain about their drop in stock and profits because of unexpected over utilization by their subscribers? They should understand that worse care promotes more care. Pay providers appropriately and utilization goes down.

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 (medicare is an exception due to site neutrality). 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 the 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 conflated to physical therapy.

Thoughts?

larry

@physicaltherapy

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