In our current health care system, there is the belief that insurance is "the only way to go". There is the perception by patients that their care, especially care such as physical therapy, is driven exclusively by their insurance plan, and that using their insurance is, in fact, the most cost-effective way to deal with an injury.

Sadly, this is no longer the case.

In the current insurance-based payment model, your insurance company will "approve" payment for a certain number of physical therapy visits for your current episode of care (and oftentimes over a calendar year). This is typically anywhere from 8 to 12 physical therapy visits. This is what CAN be utilized, not what MUST be utilized.

Physical therapists that are part of these insurance networks are usually reimbursed at a very low rate per patient or per treatment activity. In order to compensate for this, it is then in the best financial interest of the physical therapist to either a) utilize ALL available treatments that have been approved by the insurance company, or b) increase the overall cost to the insurance company in the hope of attaining a greater income based on the percentage paid by the insurance company. The average cost per visit billed by a physical therapist, based on a number of references, is in the range of $100 to $200 per visit.

The patient is typically billed a copay, and many insurance companies are also implementing a specific deductible for physical therapy or allied health services, or a percentage of the bill to be paid by the patient. Patients are now typically faced with $40 copays and up to 20% of the cost of care along with their copay. That can bring the total to well over $60 per patient visit.

More treatment visits do not mean greater improvements in function. Though the national average for back pain is along the lines of 12 visits per episode of care, most practitioners are utilizing non-evidence-based assessment and treatment strategies, and are not focusing on elements of competent self care in conjunction with clinical care provided in order to optimize the patient outcome.

Fortunately, there are some new approaches that return to a focus on quality and value in health care.

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I present to you a simple thought on the eve of our national election:

Get out and vote.

We've all spent months and months deliberating over the pros and cons of all of the candidates. I am sure that many of us have been involved in heated debateswith friends, co-workers, and family members. This has been a time of great passion. In my eyes, it means that the people of this country really do care about where it is and where it is heading - and have been very passionate about it in the process.

But let us not forget that the only way this thing called "democracy" ever works (or has a chance to do so) is if everyone gets out to vote. It's a right ... and it's a responsibility. It is one of the great freedoms we are able to experience in this great country.

On November 4, it's not so important that you are red ... or blue ... or green ... black ... or white ... but it is absolutely critical that you vote. Now more than perhaps any other time in the lives of many of us, it is imperative to exercise your rights and responsibilities as an American citizen.

By voting, we've accomplished what is perhaps the greatest part of a successful democracy. And if we don't, we are, in many ways, abdicating our rights. As I am always reminded, freedom isn't free - but on this day, the pen is truly mightier than the sword.

Vote on November 4 - and then we'll figure out what to do with it all later.

See you on the other side!

 

Let’s start with a simple premise in the world of health care – if you can’t understand the patient’s problem, then it makes it pretty hard to provide a patient with an effective solution. I think that all clinicians would agree with this premise.

Taking another step forward on this line of thought - in order to solve the problem, you need to be able to think, to reason, to “connect the dots” of your thinking, and to do so logically and based on good, sound data. I don’t think that’s much of a quantum leap in thinking either.

Sadly, this is not the clinical reality that patients experience – with physicians, with chiropractors, with massage therapists, with physical therapists, or with countless other clinicians.

That’s a strong statement that may require some explanation.

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A typical episode of care, in the current paradigm of what is “acceptable care” (note how I did not say “evidence-based care”) is 8 to 10 visits. As I mentioned earlier, this is considered by many to be “great care” and is even advertised as such. These same 8 to 10 visits are costing the patient, on average, anywhere from $64 to $80 per visit, with a total of $512 to $800 out-of-pocket for any given episode of care. This investment may not provide much value-added benefit nor quality, especially if evidence- and science-based strategies have not been implemented in competent self care strategies. Sadly, the disconnect between quality and value has become the accepted standard amongst clinicians and patients – for all the reasons that I outlined in Part I.

Add to this the fact that for every $10 spent on health care, $9 are spent on overhead. Yes, just $1 is spent on actual care, and even that is being lost in the quality/value debacle. But we also know that for every year of education, health care costs drop. So having people better educated in the process of their care makes good sense economically and culturally.

Seven years ago, my clinical practice moved from an insurance-based model to an out-of-network fee for service model. But what I have found over the years is that patients are so driven by “what their insurance covers or pays for” or “who is in or out of network”, that they fail to fully comprehend and consider the issues of quality and value. 

A fee for service model can provide an out-of-pocket cost saving, though conflicting value systems remain. Innovation can provide quality, outcome, value, and cost-efficiency, but something radically different will be required to transform our current models. Let’s examine how a fee for mentorship model provides a value proposition that is revolutionary in how we view health care, physical therapy, and health in general.

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