Probably a lot. Perhaps most. And certainly a big chunk of the bucks your insurer/TPA is paying.
Unlike surgery, imaging, drugs, and other types of medical treatment, PT has long been a bit of a black art.
The clinical guidelines for PT that do exist (with one exception I’ll get to in a minute) usually say something like ‘two visits a week for four weeks’, without describing what is to be done during those visits, who’s supposed to do what gets done, and equally important, what shouldn’t be done.
That’s the primary reason physical medicine (PT and chiro) accounts for about one out of every five dollars spent on medical care in work comp, and would account for big bucks in group if it weren’t for tightly written benefit limits (x visits at a 50% copay).
Before the PTs out there start flaming me, know that I’m a believer in the ability of appropriate PT and have seen lots of data that support the use of PT in helping injured folks return to functionality. But I’ve also audited many work comp claims where the claimant had been to PT hundreds of times. I recall one where the claimant had over five hundred (500) visits over a three year period, with each PT note looking identical to the previous one. The payer couldn’t cut off the treatment because the treating physician had ordered it, and the clinical guidelines weren’t robust enough to force the issue in court.
Last month the NYTimes had an excellent article by Gina Kolata on just this issue. Here’s an excerpt:
“My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”
So has physical therapy been tested for garden-variety sports injuries like tendinosis? Or is it just accepted without much question by people who urgently want to get better?
It depends, says James J. Irrgang, a researcher in the department of orthopedic surgery at the University of Pittsburgh and president of the orthopedic section of the American Physical Therapy Association.
“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”
(not in Ms Kolata’s article, but helpful for perspective…)
Sometimes, manual stretching by a physical therapist can actually eliminate a sports injury, he said…They are the exceptions. More common are the “voodoo” treatments, he said. And what might those be? None other than ice and heat and ultrasound, Dr. Irrgang said.
Ice and heat, Dr. Irrgang said, “can control pain a little bit” but “are not going to take care of the problem.” The underlying injury remains.”
But the lack of credible evidence-based clinical guidelines can make it difficult for payers to contest unnecessary treatment, especially in those states where regulations make it tough for payers to stop paying for unnecessary treatments.
There are credible, thoroughly researched clinical guidelines specific to PT, with the best focused not only on how many visits over how many weeks, but what should be done during those visits. I’ve reviewed all of the guidelines used in work comp for PT, and the most thorough are published by Expert Clinical Benchmarks, a subsidiary of MedRisk. (MedRisk is an HSA client)
Guidelines can’t be developed in six months; rather they must be carefully researched, assessed by acknowledged experts in the field, tested against claims and medical billing data, and reviewed periodically. There are far too many companies touting their ‘utilization review’ programs which are based on little more than the ‘same old same old’ guidelines that have never worked in the past, or quickly-assembled amalgamations of journal articles, neither of which will be of any help in front of a work comp judge.
What does this mean for you?
If you’re serious about managing PT, start with science.
UPDATE
I received an email from a good friend and colleague in the PT business who felt my post was an insult.
Let me reiterate – there are good PTs, and bad PTs.
There is good PT management, and bad PT management.
Some PT is quite useful, appropriate, and necessary, and some is not. When payers don’t use solid clinical guidelines it makes it very difficult for adjusters, case managers, peer reviewers, and hearing judges to differentiate between appropriate and inappropriate PT. And there’s lots of inappropriate PT in work comp.
In the course of my consulting practice, I’ve seen dozens of cases where claimants received more than a hundred PT visits over a year, and many where the total number was well over two hundred. This type of utilization is simply indefensible, and unfortunately often results in adoption of regulatory control mechanisms.
Some states have chosen to use caps on visits as proxies for utilization management, with 24 appearing to be the most common limit. This is at best a blunt instrument, but nonetheless it appears to have resulted in lower costs for physical medicine in the jurisdictions that have adopted the ’24 visit rule’.
Feb
12
I am one PT who actually agreed with many points on Ms. Kolata. Despite the article being semantically poor (she starts the article discussing how a patient was disgruntled regarding his limitations on PT benefits and somehow twists this around to the inadequacies of the profession), she has a healthy dose of skepticism that all patients should posses. Although I disagree with how she handled her dissatisfaction with the service she received (she simply stopped going after a couple visits without any feedback to the professional rather than open a dialogue about her goals), she decided to not play into passive treatments and questioned their value. She took the time to research the treatment she was given and found that, surprise, there is little evidence to support its use (I’m referring specifically to ultrasound).
However, you’ve taken her comment and inserted your own interpretation to suit the interest of your own post. When you quoted her:
“My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”
Inserting “that much of PT is a waste” is a pretty bold statement you are putting her mouth. This is your comment, is it not?
“How many dollars are wasted on physical therapy? Probably a lot. Perhaps most.”
I fully agree with you that clearer guidelines and better research needs to be established. However, PT is a still a rather young profession as compared to surgery and medicine, and playing catch up to our counterparts in the field is a bit of an uneven ball game. We haven’t had the time nor respective share of the funding.
However, the issue doesn’t necessarily boil down to “good PTs and bad PTs.” There are many cultural issues issues that make overutilization in PT what it is (and yes, I am agreeing that in some cases, over utilization is an issue). First, however, we must examine whether PT is being overutilized to the extent in which you are implying. Your comment about 1 in 5 dollars being spent in PT in workcomp setting has contextual boundries that go with the very patient population with which you are working. These are injured patients, PT is often at the core of their needs! Implying that PT is being overutilized in work comp just because one in five dollars is being spent there is akin examining a group of patients with cancer and saying one in five dollars is being spent on chemotherapy, therefore, it’s being over utilized when compared to a general population. When you take PT out of the context of the work comp setting, the costs spent on PT are quite little. CMS states that utilization of outpatient PT services boils down to less than 2%, despite a much larger portion of the CMS population actually utilizing services. Injured people often need PT…this is simply a fact.
Dollar for dollar, you’re probably getting more value from PT than from most other treatments. My jaw about hit the floor when you called PT a “black art” but eluded to surgery having a clearly beneficial effect. Do you really believe that? Surely, there are cases where its absolutely needed and has a clear, demonstrable benefit. However, let’s examine the 500 pound gorilla in the back of the room…back pain. Where do the vast majority of costs go? Surgery. Outside the work comp setting, the incidence of spinal fusion surgery in the US continues to elevate at an alarming rate. We have the “luxury” of claiming to be the country where spinal fusion rates sore 100, 200 to 400% on some estimates, as compared to other developed nations….all without clear demonstrable benefits. At a cost of upwards of $50,000 (for the surgery alone)…this is the monster we should be attacking.
Now perhaps it’s not on your radar because your industry has been doing a great job at preventing uneccessary and unproven surgery. In the past 10 years I’ve been a PT, I can count on my hands the number of times a work comp patient actually went for low back surgery. In contrast, I’ve had countless patients who have had an elective fusion done on their own health insurance…and guess what, the vast majority are not any better and most often, they are worse; and many times these patients had very limited physical therapy or sometimes none at all prior to surgery. It’s just too easy to stop in a surgeons office, show a little disc degeneration (welcome to life) and walk out with a surgery date. This just doesn’t happen in work comp. So let me ask you, as a manager of care, would you rather have your patient go through 24+ visits of PT, or surgery? So maybe you need to be telling yourself that you are doing a good job of preventing unnecessary surgery as opposed to over utilizing PT. Even at the whopping rate of 50, oh heck, let’s say 100 visits, your cost of care for this patient at $200 a visit (a high estimate, I know, but I’m giving you benefit of the doubt) is still far below that of one lumbar fusion.
Now certainly, 100 visits is a rare thing. It’s a rare thing for patients to have more than 24 visits, but it does happen. Sometimes, it’s based on need, more often is goes deeper than that, but I’ll get to that in a moment. Making a blanket limitation on PT services is a bad idea. It does not take into account degree and extent of injury or commodities. There are simply some diagnoses and patient populations that simply require this. CMS cap is a great example. Now that the KX modifier has been recinded, patients are now subject to this cap…about $1800 for PT and SLP combined. Now the semantics for this are a story for another day, but lets say you have a stroke…a massive one. You’ve managed to make it home, but need continued PT and most likely SLP services. At 2-3 visits a week, this will get you maybe two weeks or three of therapy…yet patients can demonstrate improvement from a CVA for up to 2 years after the incident. The options remain to go to a hospital based clinic, but what if that option is not available? Simply said, there are rare cases that need an unusual amount of PT. Arbitrary caps are a bad idea…they are process oriented and not outcomes oriented. Process based management does little to improve outcomes…it’s meant to save money and not deliver high quality care. As an example, we’ve got a carrier with whom we work who mandates that every 6 visits I perform a reassessment…I have to document pain, range of motion and strength…no matter what the problem. For my patient who had cervical myelopathy (she’s basically a person with high level quadriplegia), does taking time away from her treatment to assess and document these things, which will have little change in such a short two week period, have any positive effect on her outcomes? No…it’s a process, that’s all.
Now, does waste occur in PT? Absolutely, I agree with you wholeheartedly on this. However, this goes beyond the good PT/bad PT and lack of research issue. The point to which I eluded earlier is the cultural one. Despite PT growing in autonomy with nearly all states having some form of direct access, it is of little use to most patients…and especially those in work comp. The domineering role of the physician is still quite a demonstrative one. Despite relatively little education in musculoskeletal medicine, many physicians still try to dictate treatment. When they write orders specifically for heat, massage, ultrasound and modalities, we are bound by that. If they at least say “eval and treat” we can certainly modify this, but too many physician with relatively little education in physical therapy are still trying to dictate treatment. One of my “favorite” podiatrists insists that every one of his post op bunionectomy patients receive ultrasound and electrical stimulation, and they must receive it three times a week and “I mean it”…all this despite the fact he has not shown me one piece of evidence that ANY PT is required after bunionectomy, let alone e-stim and ultrasound. Even physicians such as orthopedic surgeons (who do have a strong foundation in musculoskeletal medicine) most often do not follow clinical guidelines for musculskeletal care. In fact, in one recent study regarding first time low back pain, orthos were less likely than PCP to follow standard care guidelines; and instead, order expensive imaging studies and NSAIDs as opposed to Tylenol and advice to stay active. …only about 50% of PCPs followed standard guidelines and less than 30% of surgeons did so. Therefore, the person who is dictating the treatment, is often the one who knows least about it. Meanwhile, the PT is forced to comply. I’ve had countless cases where a patient was clearly not benefiting from PT only to be sent back to PT by the orthopedist numerous times. It’s too easy for the physician to pass the buck onto another professional…out of sight out mind, and out of their hands (quit bothering me and go to PT…but don’t forget to pay your bill on the way out and come see me again in 4 weeks). Rather than having a frank, honest discussion with the patient about what can or can’t be done for them ( or referring them to a physician who perhaps may have better answers), it costs them little energy to simply keep writing orders for PT. In the meantime the patient has a certain expectation that it will be done…”because my doctor said I need it.”
Only when PTs are fully released from the grasp of the subservient role to a physician (except in cases where physician input is truly needed…ie, post surgical cases, etc) can we really begin to control costs in PT.
Christie – thanks for the note. I’ll respond to your points here.
1. You said “However, you’ve taken her comment and inserted your own interpretation to suit the interest of your own post. When you quoted her: “My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]…” Inserting “that much of PT is a waste” is a pretty bold statement you are putting her mouth. This is your comment, is it not?
It is indeed my comment, and it is based on Ms Kolata’s statement: “When I’ve gone to physical therapy, the treatments I’ve had — ice and heat, massage, ultrasound — always seemed like a waste of time.” Seems like a very fair interpretation on my part.
2. I didn’t claim the issue boils down to “good PTs and bad PTs.” I noted that the biggest issue for payers is their failure to use evidence-based clinical guidelines and that these guidelines do exist. These guidelines do exist today, and more should be developed, but the tools exist today, are being used today, and are effective – today. If the funding isn’t there for more guidelines, or the profession is young is beside the point. Imaging is even newer, yet there are ample clinical guidelines in existence and used for MRIs; the same is true for many new drugs and other therapies.
3. I didn’t say PT is overutilized in comp because 20% of dollars are spent on PT, you made that link. PT is overutilized in comp due to payers’ failure to use defensible evidence-based clinical guidelines, coupled with regulatory limitations. Of course PT is going to be more prevalent in comp due to the nature of the injury.
4. Your point re surgery is a fair one; there is certainly ample evidence that procedures such as carotid endarterectomies and cardiac stents can be questionable.
5. re your claim that “examine the 500 pound gorilla in the back of the room…back pain. Where do the vast majority of costs go? Surgery.”; that’s not the case in workers comp. Costs for long term back claims are disproportionately for drugs. Yes there’s a lot of surgery, much of it unsupported by evidence, but drugs account for much more of the overall spend in comp than surgical expense.
6. re your statement “perhaps it’s not on your radar because your industry has been doing a great job at preventing uneccessary and unproven surgery.”; I’ve posted here numerous times re the issue of inappropriate back surgery, the abuse of spinal implant price gouging, and related matters (search my site for ‘back surgery’). This is very much on my radar.
7. re your claim that back surgery rates are much lower in workers comp, I don’t know where you practice, but that is inconsistent with the work comp data in most states. See NCCI and WCRI for details.
8. I agree that a blanket limitation on PT is a bad idea, and said as much in my post.
9. re CVA PT, that’s an area I know little about, so I defer to your evident expertise. re musculoskeletal injuries, very, very few need more than 24 visits unless there is a course of PT pre- and post-sx.
10. I completely agree with your characterization of (many) physicians and the general lack of expertise in physical medicine, and concur that this is a primary problem. That’s a deep and broad problem, one that has to be addressed.
I’d note that the key problem is the failure on the part of payers to use existing clinical guidelines to effectively manage PT. That, the fee for service nature of reimbursement, and the power of the physician are in large part responsible for much of the overutilization plaguing the work comp industry.
Paduda