Physical therapy is one of the least understood components of work comp medical expense. This lack of understanding begins with a wide range of ‘definitions’ of what counts as PT – from services performed by physical therapists, to all the 97xxx procedure codes, to services billed by a PT clinic tax identification number (TIN).
Confusion continues when the widely varying state regulations are brought into focus, with states like Florida and California setting a hard-and-fast maximum number of visits (‘the 24-visit rule’), while others ignore PT altogether in their medical management regs, and still other jurisdictions require payers to review and authorize PT.
Physical therapy is not a price-per-service issue, but rather a number-of-services issue. Several years ago I did an analysis for a very large self insured employer that identified several claims with more than five hundred PT visits over periods of no more than three years.
That’s not a typo nor hyperbole.
Another analysis, this one for a large insurer, found over a dozen claims with more than a hundred visits over the course of a year. In both cases, there was no apparent medical necessity for the excessive visits, they were not authorized in settlement agreements, and most of the treatment records reflected massage and whirlpool treatments, repeated day after day after day.
Overutilization not only drives up medical costs, but also keeps the claimant out of work.
A recent article in the IAIABC Journal (sub req) authored by Janet Jamieson, PhD, President of the Physical Medicine Research Institute, an organization funded by PT management firm Universal SmartComp, evaluated one strategy for controlling PT visits – peer review.
Janet’s been studying the work comp world for years, so I was excited to learn of her study. Janet was kind enough to clarify several questions I had after reading the article, as I couldn’t determine if peer review had an impact on controlling utilization, and if so, if that impact was quantified.
It seems that peer review may have had an impact – possibly by reducing the number of claims with more than 24 visits (this wasn’t apparent from the article). Complicating the analysis was the underlying data; it wasn’t possible to determine objectively if there were jurisdictional differences or claim severity differences (e.g. there is a very wide range of ‘severity’ associated with lumbago). The article noted that more severe claims were probably more likely to have peer review, but that was based on the assumption (a reasonable one in my view) that lost time claims were more likely to have requests for peer review than medical only claims.
That begs the question – was the ‘right’ number of visits 24? And if the peer review program did result in fewer cases with more than 24 visits, how many of those were still excessive (the average number of visits for PT in comp is much lower than 24). And what was done during those visits, were the claimants ‘shaked and baked’ or was there actual work hardening and therapy designed to increase the patient’s functionality?
One finding of note was that active involvement of the payer appeared to reduce the number of visits more than the possible impact of peer review itself. That is not surprising; employers with strong risk management, injury prevention, and claims management programs always get better results than those who rely on utilization review alone.
As with almost any study, more questions were raised than answered.
Jun
17
As the National Director of Outcomes for both a large national rehabilitation provider and physical therapy network, I read with great interest the recent study by Dr. Jamieson as I presented analysis of a similar Peer-to-Peer Utilization Management program administered within a large provider organization at the 2009 ACOEM American Occupational Health Conference. In reviewing Dr. Jamieson’s manuscript it appears we used nearly identical inclusion criteria, and my organization’s UM program carries out the administrative tasks described in the section regarding the “nested” sample of patients who were both prospectively and concurrently managed.
My analysis of ~100,000 unique episodes-of-care for workers’ compensation Back and Shoulder injuries (all diagnoses) demonstrated statistically significant reductions in the variation of both visits and length-of-stay, bolstering the statement in the manuscript “…even when the prospective peer-review information is provided the information is not used by the case or claim manager for managing the medical component of the claim.”
I could not agree more.
In my companies’ systems, we perform both prospective and concurrent review, utilizing a set of visit benchmarks that are adjusted for the workers’ compensation payor class, primary diagnosis (ICD9), patient age, and post-operative status. This allows prospective assignment of a benchmark guideline, and when that guideline is met, triggers a peer-peer review process that requires communication with the external stakeholder managing the case. Utilizing this combined strategy I have measured significant reductions in utilization while concurrently maintaining all clinical quality parameters.
Jamie Stark, PhD
Just to clarify, Florida statute limits chiropractic visits to 24 but does not limit other providers of physical medicine (PT, OT, MD, DO, et al)
You make an excellent point about the distinction between Physical Therapy – which is a professional service rendered by licensed therapists and the general /generic use of 97000 “Physical Medicine” codes.
Overutilization seems to be rampant across all sectors of healthcare as the economy tightens up.
However, overutilization of “Physical Therapy” within workers’ compensation is somewhat of a puzzle because:
1. All “Physical Therapy” has to be authorized by the payer. The median number of visits in workers compensation for “Physical Therapy” generally hovers around 16. So ramping up accountability at 16 visits, for example, would seem a simple strategy to address the outliers. It may well be that 100 visits for someone suffering a major closed-head injury would be appropriate. More than not, however, I suspect economics drives utilization.
2. Even more fascinating is the fact that all of those visits were deemed medically necessary by someone. In workers compensation ” PT” is generally only provided upon referral from an authorizing- gate-keeping physician. So if utilization is going through the roof, a good strategy might also be to see if an economic conflict of interest might be at play. Here in Florida there has been a huge proliferation of physician-owned PT practices. It’s a sweet business model: the physician owner has the exclusive authority to determine medical necessity AND controls the delivery of the service as well. In the face of overwhelming evidence that this conflict of interest is a major cost driver, it’s a wonder more payers don’t just refuse to authorize PT when delivered in a physician-owned setting.
3. Lastly – many payers simply don’t seem to get the idea of aligning incentives. Discounting procedures to a level below the providers cost always results in a compensatory increase in visits. The literature is clear. The experience is well documented. And the solution isn’t that complicated – make sure the per-visit rates are fair, then control episodic exposure by monitoring outliers. In fact, there is a HUGE data base of clinical and economic outcome data available from FOTO (Focus on Therapeutic Outcomes) – payers ought to use science and data rather than the failed strategy of line-item discounting.
But bureaucratic inertia is apparently difficult to overcome