How Many Dollars are Wasted on Physical Therapy?

Thursday, February 25, 2010 | 1

How many dollars are wasted on physical therapy?

Probably a lot. Perhaps most. And certainly a big chunk of the bucks your insurer/tthird-party administrator 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 more than 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 New York Times 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."

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 that 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'.

<i>Joe Paduda is principal of Health Strategy Associates, a Connecticut-based employer consulting firm. This column was reprinted with his permission from his blog, http://www.managedcarematters.com</i>