The American Healthcare System Has Disrupted My Physical Therapy Practice
The amount of red tape and confusion around HMOs and PCPs has really hurt my patients and their rehabilitation.
I’m a physical therapist, and my occupation has many different meanings to many different people. To some, I’m a personal trainer; to others, I’m a massage therapist. And to those that understand my holistic approach to therapy, they see me as a healer. Over the years, I’ve experienced a wide range of patients with different expectations of me.
Through the lens of those I treat in the clinic, I’m very helpful and am able to guide them through their recovery process from an accident, injury or recent surgery. Those that have had the experience of my home treatments understand the way my hands can heal them and that the use of energy work tied together with manual therapy can manipulate their bodies to have incredible results.
Time in the health care world is everything. Let me explain what I mean by that. Time, for a patient, revolves around several factors: recovery time, initial evaluation time, between-treatment time, during-treatment time. For a therapist in an office, time revolves around only two factors: reimbursement and commute. Time is also a valuable tool when you’re appropriately being compensated, and you can spend it by helping to heal a patient and reduce the number of sessions and length of their recovery with focused therapy and treatment programs.
I’ve been working in my field for a short time in comparison to most physical therapists, but I’ve been able to treat many different kinds of patients and clients from all walks of life. They range between homeless patients that don’t have any insurance to the extremely wealthy clients that prefer not to deal with any insurance companies because they’d rather have no record of treatment.
Clients With Different Health Plans Can Cause Major Complications
As an employee of several different therapy groups, I had been instructed to quickly discharge patients with low-paying health maintenance organizations (HMO) and encourage them to use a home exercise program (HEP), while keeping on patients with higher-paying preferred provider organization (PPO) plans. The reason for this is because the reimbursement rate for PPOs is significantly higher than that of HMOs.
The job becomes more difficult when HMO clients are scheduled with other patients; they get stacked during the same time slot without being staggered during the actual appointment blocks. There is a huge imbalance in this country's health care system, and it is only going to get worse as long as insurance companies are setting rates based only on volume and not outcomes.
Bringing therapy to the masses is a very difficult task because properly educating patients and helping them through their recovery journey takes time. When time is taken away, you’re left with half-treated patients that aren’t able to be independent with a HEP, or with patients that require more sessions when they’re discharged from care. One time, I was treating a patient diagnosed with a frozen shoulder. She was finally starting to achieve some of her functional goals—like raising her arm overhead to get objects off of high shelves—but before she could get her shoulder all the way up, her sessions ran out and it took her several months to get another referral to continue her care.
The intent of this article is not to belittle HMOs as a health insurance strategy—they work very well for people that are healthy and don’t require a great deal of care. They also work well for those able to advocate for themselves in the system. I’ve seen a lot of people get coverage for different resources that I didn't think were possible, but through the proper advocacy, they got what they needed.
It’s Important You Understand the Medical System and Ask the Right Questions
One of the major problems that I’ve seen working within the HMO system, however, is the need for referrals to get services. That means that the primary care physician (PCP) is the gatekeeper of care. Without a recommendation from your PCP, you’re not eligible for further resources. An example of this is if a patient has some kind of medical issue that the PCP does not know how to, or is not willing to, handle on their own. The physician then creates a referral to move the patient to a specialist. The specialist could refer the patient to get imaging, and then to a surgeon, physical therapist or someone else.
This is a big issue because it can take a lot of time for referrals to be approved by the HMO. I’ve seen this play out in very catastrophic ways—with a patient starting with a small pain in their shoulder then needing to wait months to see the orthopedist, then a few more months to get imaging, followed by more waiting and then finally getting referred to see the physical therapist. By then, they’re unable to move their arm above their head without extreme pain.
The medical world is complex and continues to get increasingly complex as time goes on. Through my short but thorough years of experience, I have learned that knowledge is power when it comes to knowing and understanding our medical system. And if you really need something done, call offices and check back with doctors to make sure they’ve filled out the paperwork to stay on top of your health. Keep asking questions.