The Value of the Cost of Treatment
This article http://wapo.st/187qp1A was shared on Twitter early this morning by physical therapist Justin Feldman (@JNFeldman), with the comment “A good argument for #cashPT.” As I clicked the link and saw the title, my heart sank. It said:
For a stiff neck, nearly $6,000 in physical therapy seemed too much.
The article was an op-ed from author, Chris Core, a commentator for WTOP radio. In it, he described his experience with physical therapy for his neck. Suffice it to say, he did not have a good experience. I have a number of thoughts after reading his perception of the experience, so indulge me while I share them.
In my Pain Sciences course work with Myopain Seminars, we were told that “the pain is where the patient says it is, when they say it is, and it is as bad as they say it is, because it is THEIR pain.” (Once we come at it from that perspective, we can begin to shift their experience and emotions around the pain as we partner with them in treatment).
So, working from that paradigm, I would like to say that Mr. Core’s experience with physical therapy was as bad as he says it was (because it was HIS experience). None of us know what happened in his evaluation and one subsequent treatment; but, he states that he was asked a bunch of silly questions and then given a massage and some exercises, and sent home. We need to appreciate his take on what he experienced.
As a physical therapist, I ask the same “silly” questions of every new patient. I ask a lot of questions. Tons of questions that may seem irrelevant to the patient: “How is your sleep?” “Is the pain sharp or more of a dull ache?” “How long do you work on the computer without taking a break?” “How is your diet? Do you drink a lot of coffee? Soda? Eat a lot of processed foods?” “Have you been hiking lately? Did you ever notice a rash or mark on your skin? Ever see a tick on your skin?” And on and on….these “silly” questions help me to understand factors that may contribute to the current complaints of pain.
Lesson #1: We need to tell our patients WHY we’re asking these questions. We need to explain that we need a complete picture of their overall health to develop a treatment plan. If we don’t explain the method behind our madness, we may be perceived as nosy and intrusive (or worse, clueless).
In the initial session, after the evaluation, the therapist provided some sort of manual therapy. We have no idea WHAT the therapist did; but, the patient’s perception was “The therapist rubbed my neck and shoulders a bit.” Yikes! Maybe that’s what happened. Or, maybe the therapist was continuing to assess the patient’s soft tissue. Or maybe she was doing manual therapy including mobilizations or Muscle Energy Techniques or…something. The fact remains that the patient walked out and told everyone that he got a “massage” at physical therapy. Fail. When we provide any treatment, we need to explain to the patient what we are doing and more importantly WHY that is the indicated treatment. If the patient doesn’t understand the treatment, how can we possibly expect them to value it?
Lesson #2: Explain everything. Fully. Until you are sure the patient understands the purpose of what you are doing.
Mr. Core shares that when he saw the doctor he was referred to physical therapy. He says, “One of the therapy clinics was in his building, so I stopped by on my way out to make an appointment for later that afternoon.” Now, we can take a guess and say that the clinic may have been a POPTS (Physician Owned Physical Therapy). Maybe it was…it is legal in Virginia for physicians to own physical therapy clinics. Or maybe the clinic just happened to be in the same Medical/Professional building as the doctor. Let’s not get into the whole POPTS issue here. The important thing is that the patient SHOULD have been handed a list of physical therapy clinics that he could check out. It would then be the patient’s responsibility to investigate each clinic and to ask questions of their insurance company about the coverage of their individual policy.
Lesson #3: Patients have a choice of where they go to receive physical therapy and MOST have no idea that this is true. Most patients will go to whatever clinic their doctor recommends (or the clinic closest to their home/work). Patients will spend more time asking for recommendations for a hairstylist than for a physical therapist. We need to develop a greater presence in our communities, and educate the public about the fact that they can choose where to go for treatment. We need to educate the public on what to look for in a “good” physical therapist (let’s not debate what constitutes “good” here – let’s leave it as ‘a therapist should utilize Evidence Informed Care in a welcoming environment’). And we need to change the culture of patient as passive recipient of Healthcare to active partner in Healthcare.
After the initial evaluation and one treatment, Mr. Core went out of town. He states, “Be it the muscle relaxers or the exercises, my neck was much better at the end of my trip, so I never did call them back.” Now, I’m not judging the fact that the patient didn’t call the clinic back, after all, he saw no value in what he had already experienced…but, my guess is that whatever the underlying cause of his pain was, it was not fully resolved in one visit. For whatever reason, the treating therapist did not help the patient to understand the importance of making lasting changes to minimize the chances of the same exact problem happening again.
Lesson #4: We need to articulate the WHY behind the treatment plan, and help the patient to commit to making lasting changes. This isn’t easy. We are all conditioned to want the quick fix. Education is the key to helping patients make the commitment to change. The goal of our treatment should be twofold: first, provide care to decrease the current pain/dysfunction (in a few treatments as possible), and second, to teach the patient what to do on their own to manage the pain and decrease the chance of future incidence.
With respect to the cost of his care, Mr. Core states
“My insurer had been billed $412 for my first appointment and $384 for the second. I can hardly blame the company for wanting to know the justification of such costs.
As I look at it now, the charges seem excessive. There is little justification in my mind for the $800 my insurance company was billed. Had I been told the costs upfront and been expected to pay for them, I would have said no. But nobody volunteered the information, and I didn’t ask.
Perhaps a place for health-care reform to start is with full disclosure of costs. If we customers are aware of what our insurance company is being billed for, we could do our part in holding our providers responsible for excessive costs and unnecessary treatment.”
I totally understand Mr. Core’s thoughts on the cost of his care. What patients do not understand is that insurance companies only reimburse a small portion of what is billed (hmmm….maybe we need to start there), which is part of what drives up the cost of care. Depending on the insurance company, the clinic may have been reimbursed less than $100.00 for each visit. And, as an aside, hot packs aren’t billed in physical therapy because insurance doesn’t reimburse for them. So, while providers DO need to be held responsible for not billing excessively and not providing unnecessary treatment, the patient ALSO needs to hold his/her insurance company responsible for the extremely low reimbursement rates for physical therapy. It’s a vicious cycle.
Lesson #5: Physical therapists need to do our part in keeping the cost of care low AND patients need to hold their insurance company responsible for actually paying for care.
It’s unfortunate that Mr. Core had such a bad experience with physical therapy. Not all of us are inept. Or crooked. Or clueless. Most of us want to help people get out of pain and move better. Many of us have pursued the highest possible levels of education in our field. Very few of us are out to cheat the healthcare system, and certainly none of us are getting rich doing what we do. So, Mr. Core, I apologize for the fact that as a profession, we didn’t help you to see the value of physical therapy. We’re working on that. As Warren Buffet says, “Price is what you pay. Value is what you get.“ In the meantime, if your neck hurts again, there are a number of us who would be happy to treat you, and to help change your perception of our profession. Word of mouth is pretty powerful…you know?