Insurance-Driven Health Care and Chronic Pain — How Can I Heal and Recover?
In the United States, insurance companies typically dictate the quality and quantity of the health care we receive; to obtain in-network care, we are told where we can go, who we can see, and how many visits are covered.
In-network health care providers face constant pressure to limit treatment sessions to even less than the covered number of visits; it's not uncommon for a provider to be informed that they must discharge patients more quickly in order to retain their contract with an insurer. For example, while an insurance plan may allow 20 visits for treatment of low back pain, a provider may be advised that 6 visits is the maximum that will allow them to remain competitive with another clinic, where patients are discharged after only 4 visits.
This race to discharge occurs whether the problem is acute (i.e., 3 months or less since onset of symptoms), or chronic. Not every problem develops instantly after an injury; some develop over time, or may be an issue that the patient has been suffering with for years. After 4 or 6 visits, has a patient healed and recovered from a chronic problem? No, what has happened is that the insurer has saved money, the provider couldn't adequately care for the patient, and the patient didn't get the care they needed.
There exists a movement toward 'pay for performance' in the health care industry; the basic idea behind this movement is to financially reward or penalize providers based upon their ability to achieve optimal outcomes in the least amount of time. While quality improvement is obviously important, I'm concerned that this model will reward only those who care for patients with uncomplicated, localized, and acute problems, the kind that can be easily and quickly resolved. Providers may simply avoid patients likely to lower their performance scores, focusing instead on those with the type of simple problem that can be effectively treated in the 15 to 30 minutes of one-on-one care that an in-network provider is allocated.
15 to 30 minutes is an adequate amount of time to address, for example, a simple stiff joint problem, using exercise instruction and joint mobilization techniques, but it's not enough time to address soft tissue dysfunction. In a pay for performance model, what happens to those patients who deal with chronic, complicated, or widespread problems? Many of the patients who have sought me out have suffered not only from chronic back pain; they've also struggled with neck pain, headaches, or chronic pain in many areas of their body, preventing them from moving well and enjoying life.
Is a treatment plan of discharge after a handful of visits to an independent home program, without a decrease in pain or an increase in mobility, a good outcome for that person? Does it meet their goals of healing and recovering from their problem? Should they just have to learn to live with their pain, and accept an insurance-driven model of health care that tells them nothing further can be done to help their problem? NO!
I offer a different perspective and specialized treatment approaches to people struggling with chronic pain; I am able to provide this kind of care by being a highly trained out-of-network provider.
For treatment of soft tissue dysfunction, a common cause of chronic pain, I specialize in a type of manual therapy called Myofascial Release, spending a full hour one-on-one with each patient, addressing the underlying problems causing pain and lack of mobility. Home exercises are used to maintain and improve upon changes made during treatment sessions, not as a stand-alone treatment. Not until after spending the time needed to allow people to heal and recover are they discharged, either to an independent home program or to monthly follow-up health and wellness care.
My patients receive care that allows them to get their lives back and enjoy living again, no longer plagued with pain, moving freely and without fear.
Medicare is complex, and seems to become more complex with each passing year. The system has reached a point where it's too difficult for a practice without a dedicated billing team to navigate the complexity; even large practices with such teams are struggling with ever-increasing requirements and significant penalties for honest or minor mistakes. It's therefore becoming increasingly common to see physicians "opt-out" of Medicare, instead directly charging the patient for services provided, in order to avoid the risks associated with billing Medicare.
Unlike physicians, Physical Therapists aren't allowed to opt-out of Medicare. This results in the following situation with respect to physical therapy services:
If your treatment under Medicare has reached a point where further treatment would be termed "maintenance" by Medicare, but you have not yet reached a level of decreased pain or increased function that is acceptable to you, I can then treat you as a fee for service patient, not reimbursable by Medicare. Prior to treatment, you will need to sign a Medicare Advanced Beneficiary Notice ("ABN") form. This form is a written notice that a therapist gives to a Medicare beneficiary, prior to provision of service, when the therapist believes that Medicare will not pay for some or all of the treatment.
The above may seem puzzling or confusing; it certainly is to me. I encourage you to contact me if you are interested, or need further explanation.
When I moved back to California from Vermont in 2004, and began to look for a Physical Therapy job, I was surprised by how little time potential employers expected me to spend with patients. Often they allowed no more than 15 minutes with a patient.
When considering the paperwork involved with each patient, that would have been something like working in a mill. Basically, check in with the patient, then do whatever would be minimally necessary to hand them off to an aide.
Fortunately, I was able to find a clinic that held to a strong philosophy of effective patient care, and thus was able to avoid mill work.
Therapists treating many patients per hour are typically "in-network providers". That is, they've negotiated a billing rate with one or more insurance companies, and as a result must sustain a high patient turnover rate in order to remain afloat. This is burdensome for both the therapist and the patient, and the effectiveness of such treatment seems questionable.
One way for a practice to avoid a mill situation is to bill the patient's insurance as an "out of network provider"; any amount not paid by insurance is expected to be paid by the patient, including any charge added to cover the cost of the billing specialists. However, there is often significant lag time prior to being reimbursed with this model, and insurance companies often employ delaying tactics to deny reimbursement to the therapist for as long as possible; it's obviously difficult for anyone to not be paid for an indefinite period of time.
As a sole practitioner interested in providing the best possible care to my patients, neither of these approaches seems to be viable. I've elected to go with a third, simpler approach.
I treat patients one-on-one for a full hour, without the use of an aide; this level of care, in my experience, allows patients to get better faster with fewer visits, thus improving their quality of life more rapidly.
I accept payment from the patient at the time of service, and provide a written statement. The statement, along with any necessary additional documentation, can then be submitted by the patient to their insurance for reimbursement.
In this way, I can focus on what is most important: caring for my patients, and providing a customized treatment approach that addresses individual patient needs and goals.