The Value of the Cost of Treatment

The Value of the Cost of Treatment

The Value of the Cost of Treatment

This article 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?

  1. As a PT in independent practice for 32 years I could not agree more.

  2. Ann,
    Great post! I agree completely too and I haven’t been a PT nearly as long as Bruce. 😉 The patients’ experience is paramount to our success.

    A couple of other points stand out to me. While the recommended 11 sessions might total around $6,000, Mr. Core’s out of pocket expense was only $20. It seems a bit sensational to write a headline implying that it was $6,000 to get his neck “fixed.”

    Those two sessions were only worth $20 to him, until he saw what his insurance was billed.
    I completely understand the disconnect. Patients have a perceived value of only what they pay for their treatment and when that is a low amount such as a $10 co-pay, it understandable that they may be exasperated when they receive a statement or even a bill showing the billed amount as well as any remaining deductible balance they may owe.

    I do think that the front desk “urging” him to book 11 more appointment prior to his evaluation or even receiving a recommendation from the therapist is highly suspect and reminiscent of fraud.

    The other possibility, in a perspective similar to what you propose, is that the front desk person and the therapist were just being employees doing their job treating the condition, not necessarily there caring for the person. I felt disgusted at some of my fellow classmates in PT school when they told me the reason they were in school was because that’s what they are supposed to do with an exercise and sports science degree. For some people this is just a job, not their passion.

    Your quote from myopain seminars resonates with me too. If we don’t meet our patients affective needs by letting them know we know where they hurt (by touching that area) then we are doing them a disservice and will be unable to get that patient to buy in to what ever treatment paradigm we are using.

    I too feel terrible that this and other stories of bad customer service and experiences are making headlines. Is this just a problem of the patient’s perception? lack of patient/public education? or the total lack of accountability when the person receiving the service is not the same person paying for it? of the current model of healthcare?

  3. After about ~ 20 years in occupational therapy, I have seen this in outpatient, acute care, and in acute rehab. People seemed conditioned not to ask about their healthcare choices and costs.

  4. Ann,

    I think you did a great job of taking a patient’s valid concerns and making some excellent suggestions on how we can do better in the future. I work for a hospital PT system and have previously worked for a private practice, and the charges and reimbursement thing always drives me crazy. It doesn’t make much sense for the patients (or for health care providers) and I wish we were doing better. In that way, I definitely envy cash-based PT providers. It is really, really challenging for patients to be informed consumers of health care when we have a difficult time giving them exact prices of care and it is confusing that whatever we bill is not what they or their insurance company pay. I hope we can continue to figure out a better way to streamline these things.

    Thanks for such a great, thoughtful response to the article with constructive suggestions.

  5. Ann,
    First I could not agree more with everything you wrote. Great post. I am happy to update all you and your readers that after reading the article I took advantge of the “email the author” link and reached out to hip. He responded today and was very receptive to our thoughts on the issue.

  6. Very good article!

    Patients not only benefit from having a broader picture of their own care, but they deserve it. As you said, it is their experience, their body, and their money, money they trust to have put to good use. If the patient feels their time is being wasted by otherwise useful questions, they deserve to be informed of why they are useful. It benefits not only the patient, but you as well.

    This would be particularly beneficial for workers’ rehab, specifically on how to communicate better between patient and P.T.. Physical Therapists can be certified to care for workers’ compensation rehabilitation cases. I would recommend P.T.’s to check out the CWcHP certification, it brings P.T.’s directly into healthcare. Here’s the link:

    Anyway, great article. Keep it up!

  7. Hear hear! Thanks for such an articulate article and presentation of the problems we go up against in our own profession as well as in the individual health care spectrum. That said, I do think it was a POPTS- who would charge that?!!

  8. Ms. Wendel,

    As an undergraduate Kinesiology Pre-Physical therapy student, I believe that your post was an excellent piece that professionally analyzed Mr. Core’s unpleasant physical therapy treatment. I agree with you that therapists need to clearly explain to their patients the reasoning behind prescribed exercises and therapy techniques. While the focus of Mr. Core’s post was about insurance bills, I believe that part of his dissatisfaction with physical therapy was his lack of education and knowledge of the reasons behind the exercises his therapist instructed him to do. According to the American Physical Therapy Association, the job of a physical therapist is to help reduce pain and improve or restore mobility, as well as educate patients on how to manage their condition and prevent future occurrences. Physical therapists need to remember that they are educators to their patients. The patient population is diverse, varying in age, gender, and knowledge of the human anatomy and physiology. Therapists have to assume that the patient does not know anything about rehabilitation and in your own words, “explain to the patient what we are doing and more importantly why that is the indicated treatment.” As a student sitting on the border between patient and physical therapist, I always question the therapists I work with about their rationale behind the exercises and manual techniques they do with their patients. If I do not understand what you are doing during the appointment, then the patient is probably clueless too. One of the first things I believe that therapists should make clear to their patients is that physical therapy is not limited to what is done in the clinic. Physical therapy encompasses in person treatments usually once or twice a week as well as the home exercises therapists prescribe. The improvements patients see in range of motion, function, and strength at each therapy visit is the result of the home exercises. If therapists explain and stress the importance of these home exercises to their patients, then I foresee that patients will more likely value them and take the time out of their day to complete their home exercise program.

    I believe that another source of patient dissatisfaction is the rise in what Dr. Carlos Berio, PT, DPT, MS, CSCS, CMTPT calls “Physical Therapy Mills.” As the number of people needing physical therapy increases, especially in geriatrics, therapists are pressured to focus on treating as many patients as possible instead of taking the time to provide quality treatments. At some clinics, appointments are only half an hour long which is usually not enough time for the therapist’s treatment and the patient’s exercise routine. From observations and working as a physical therapy aide in over 5 different settings, I know that most therapists hand off their patient to a physical therapy aide or assistant while they go treat their next patient. Most patients are not treated solely by their therapist which could contribute to low patient satisfaction scores. In 2011, Australian researchers conducted a study and found that patients were more satisfied when they were treated by the same practitioner over the course of treatment. According to the researchers, “Patients need to feel that they have had adequate time with the therapist and not feel rushed through an appointment. Reducing patient-therapist time can be interpreted by patients as a lack of interest in them and lead to lower satisfaction.” While having an aide or assistant work with a patient is helpful to the therapist, I believe that the whole length of the scheduled appointment should be conducted by the therapist and only if the patient decides to stay longer to do the unfinished exercises in the clinic instead of at home, an aide or assistant can help. My plan ensures that patients get the full treatment time with their therapist and also help with their exercises with an aide or assistant if necessary after the appointment’s completion.

    Overall, I think the key to increasing patient satisfaction is to improve on establishing strong patient-therapist relationships. Therapists should spend more face to face time with their patients and not only be professional, but also personable so patients can be comfortable with and trust their therapists throughout their treatment period which could span from a couple of weeks to a few years. These goals all start with strong communication skills. Therapists need to be better educators to their patients which unfortunately is not an easy skill to learn. There are reasons why there are college classes on public speaking. I believe that we should start by adding patient-therapist communication classes into the physical therapy school curriculum. After looking at five of the top 30 Doctor of Physical Therapy (DPT) programs, I only found one program that included a course on physical therapist as an educator/communicator. By emphasizing strong patient-therapist relationships from the first year of DPT programs, students will have time to learn and develop techniques for treating a variety patients in the future. The learning does not stop at graduation, as seen in Mr. Core’s post where he specifically noted that he was “assigned a therapist who was only a year out of physical therapy school.” The patient and therapist are a team working together through the recovery journey and strong team is only as strong as the relationships between its team members.

    Helen Yiu
    University of Southern California
    Dana and David Dornsife College of Letters, Arts, and Sciences
    B.S. Kinesiology, Psychology Minor
    Class of 2015

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