If you’ve been a part of the physical therapy profession for any length of time, I don’t have to tell you how many barriers stand between patients and access to quality physical therapy care. From skyrocketing premiums to restrictions on direct access, it often feels like the odds are stacked against us. In fact, during our recent industry-wide survey, rehab therapists ranked insurance requirements as the top barrier to accessing patients before they see a physician. The second most prevalent barrier: high copays and deductibles. Perhaps you’ve noticed a theme here: both of these responses relate directly to third-party insurance payers. Now, it’s not earth-shattering news that insurance companies aren’t always willing to play ball with physical therapists. PTs frequently point to low payer reimbursement rates as the culprit behind slim profit margins and financial difficulty. And considering the fact that insurance payers probably aren’t going anywhere for the foreseeable future, that’s a big problem.
A heftier price tag means fewer patients are willing to pay.
To make matters worse, physical therapy services are often financially burdensome for patients—even those with robust insurance coverage. For one thing, private insurance premiums are much higher than they were in years past. As we mentioned in a recent post on the WebPT Blog, the National Conference of State Legislatures reported that annual premiums for individuals with employer-based health insurance “reached $18,764 for 2017, up 3 percent from 2015 for an average family coverage with workers on average paying $5,714 towards the cost of their coverage.” Individuals seeking private-market coverage in 2018 found “the average increase with subsidies was $201.” Worse yet, those climbing rates do not typically coincide with commensurate expansions in coverage for physical therapy services. As a result, patients are less likely to seek out a PT when an alternative service or procedure with a lower upfront cost is available—even if that alternative is more invasive and risky. Ultimately, that means less favorable outcomes for patients with musculoskeletal conditions as well as poorer health for patients overall.
Providers and payers want the same thing.
All things considered, it’s really no wonder that insurance companies have such an unsavory reputation. Many healthcare stakeholders—including patients, rehab therapists, and other providers—see payers as the enemy, calling to mind images of corporate fat cats counting stacks of money in gold-plated offices. But is that really the case? Or, perhaps a better question is, “Is it in our best interest to continue villainizing them?” As PTs, we tend to see this dynamic as an “us versus them” sort of battle, but in reality, we’re both working toward the same goal: controlling costs and optimizing patient outcomes. In other words, we both want quality and value. So, why do PTs and payers seem to be at odds?
The Specialist Situation
As we’ve explained before, part of the problem is that insurance payers tend to categorize physical therapists as specialists—a distinction that further ingrains the misguided belief that patients need a physician referral in order to see a PT, thus creating a greater divide between patients and physical therapy services. As WebPT’s Brooke Andrus explains here, “Physical therapists typically fall into the specialist category, and on the surface, that designation makes sense. After all, PTs specialize in the treatment of musculoskeletal conditions. The problem is that insurance plans often require beneficiaries to contribute higher copayments for specialized care.” Combine this with that fact that physical therapy patients typically attend multiple sessions a week—with most insurance plans requiring patients to pay a copay at every visit—and swallowing that cost becomes more and more difficult on the patient end.
A Data Deficiency
And here’s the other question: how do payers set those rates to begin with? Well, in essence, insurance companies base their reimbursement rates, coverage decisions, and policies on data. So naturally, the rates they select will depend on the data they are able to access. Unfortunately, the data points they have—those around cost and utilization—only tell half the story. Without outcomes data and patient satisfaction data (e.g., NPS), payers have zero visibility into the ROI of their spending. So, of course they wouldn’t increase that spend without knowing what the results may be—and without having a way to measure those results. That’s just smart business.
On the provider end, we know that physical therapy is a viable, cost-effective, and safe treatment option for patients with musculoskeletal conditions. The research is there, which would lead one to believe that payers should be sending beneficiaries to physical therapy in droves. Yet, here we are, still fighting the same old fight.
We must create the change we want to see.
So, now what? Should PTs sit back and accept their fate as overworked, underutilized, and underpaid specialists? Or is there a way we can work with payers to demonstrate our effectiveness as first-line providers, as well as the overall efficacy of physical therapy treatment? And if the latter is possible, where do we begin? I believe we must start by showing payers that we are an asset, which as this article from Physicians Practice explains, is what payers need most. And the first step toward doing that is showing them the meaningful outcomes and satisfaction data we’re already collecting every day.
In the past, payers have attempted to collect more comprehensive data around patient gains throughout therapy treatment (with programs like PQRS and functional limitation reporting [FLR], for example). Thus far, however, these attempts have failed to yield any usable information. (In the case of FLR, CMS has actually admitted that it might be time to return to the drawing board and find another method for collecting this type of data—which is an indication that payers really do want to understand the full picture.) Clearly, there is still a great need for payer visibility into therapy provider outcomes, and I believe it’s up to us to deliver the data that shows the entire healthcare world—payers and patients alike—just how valuable we are.
PTs hold the keys to driving real change.
I know some PTs are hesitant to share this data with payers, and that largely stems from the dark picture we’ve painted of them—and the resulting culture of distrust. These practitioners assume that if they share their data with payers, then those payers will use it against them. However, when we withhold that information, insurance providers aren’t getting the whole story—and ultimately, that holds our entire profession back. Payers already know that physical therapy is cost-effective, but the cost data alone isn’t enough. They need to know that their beneficiaries will actually get better and achieve their functional goals as a result of the care we provide. Once that happens, we can start working with them to establish clinical pathways that will funnel the right patients to physical therapy.
I also believe that all of this must begin with a conversation. In fact, during this year’s Ascend conference, one of our keynote speakers—a representative for a major commercial payer—will provide first-hand insight into how insurance companies think. This will give all attendees the opportunity to step out of the ring, approach reimbursement with a fresh perspective, and really try to understand payers’ logic and motivations—which will ultimately help us find common ground.
By shifting our view of insurance companies from “adversaries” to “partners in health,” I believe we can truly elevate our profession. Helping my fellow PTs achieve greatness in practice has always been my mission, and it’s something I strive for with every new venture—from creating a rehab therapy-centric EMR to hosting the aforementioned Ascend summit. (I’m particularly excited about this year’s conference, not only because we’re hosting it just a few blocks away from WebPT HQ in Phoenix, but also because our speaker lineup includes all-star industry advocates such as APTA President Sharon Dunn and compliance expert Rick Gawenda.) If we can step away for a moment and look at the big picture, our patients will benefit in the end—and that will help us get the PT profession a seat at the healthcare table. And that, in turn, will allow us to access more patients—and be more valued and respected—than ever before.