An unstable environment troubles independent PTs

By Mike Pettinella Daily News Correspondent | 0 comments

LE ROY — Privately-owned physical therapy practices are receiving inadequate treatment when it comes to issues such as health insurance co-pays, physical therapy as an alternative to surgery, workers compensation laws and freedom of choice, according to a local physical therapist and leader of a Western New York PT coalition.

“It all comes down to being treated equitably and fairly,” said Patrick Privatera, president of Le Roy Physical Therapy & Village Fitness and president of the Physical Therapy Alliance of Upstate New York.

“Insurers categorize physical therapists as ‘specialists’ just like orthopedists, neurologists, cardiologists, and other physician specialists but they fail to appreciate that our practice patterns are very different. A patient might see a physician specialist two to three times per year to treat a given condition, but patients might see a physical therapist two to three times per week during an episode of care. When specialist co-pays are set at $40 per visit, you’re seeing very unequal coverage.”

In recent years, insurance companies have raised premiums charged to employers and subscribers. Despite this trend, Privatera said, costs of care are being shifted back onto the consumers.

“Co-pays for physical therapy are a great example,” he said. “There has been very little change over the past 10 years in the fees insurers pay or allow for a physical therapy visit, but insurance premiums seem to increase by 10 percent every year, and co-pays for PT have risen from $5 to 10 per visit to up to $50 to $60 per visit.”

Privatera said that patients may think that physical therapists are making more money due to the higher co-pays, but that’s not the case.

“Ten years ago, a patient might have had a $10 co-pay on a visit with a $42 allowance, meaning the insurance company paid us $32. Now, the patient might have a $40 co-pay on a visit that pays us $42. The insurance company pays us only $2. In more and more cases, the insurance company pays zero as the co-pay is more than we are allowed by contract, but tells the patient they have a physical therapy benefit.”

He also said that Kentucky recently passed legislation that caps the patient’s responsibility of physical therapy costs to 20 percent. “That’s what we’re hoping to achieve,” Privatera said. “It should be co-pay; right now it’s ‘me-pay’.”

Privatera said he also is concerned about the perception that physical therapists aren’t qualified to diagnose injuries.

“Today’s PTs graduate with a six-year clinical doctorate degree, and several studies have established that a physical therapist’s clinical diagnostic ability parallels or exceeds that of a primary care physician,” he said.

Furthermore, Privatera said physical therapy treatments often are more cost effective.

“There is a lot of data to support the efficacy of PT over many traditional and more costly treatment options,” he offered. “Billions are spent each year on unnecessary surgery, diagnostic imaging, injections, and pharmaceuticals … and physical therapists are in a position to curb these costs.”

He cited osteoarthritis as an example of this.

“With a large increase in total hip and knee joint replacements forecasted as the baby boomers age over the next five years, and with costs in excess of $25,000 per surgery, PT should be much more engaged in disease management algorithms,” he said. “Our alliance has tried to meet with insurers to discuss this, and they seem to pay us lip service in support, but have been unwilling to collaborate on our innovative ideas or to make any significant changes to policies or procedures.”

Privatera said that physical therapy has historically been viewed as a commodity — “a thing instead of the experts that we are. We’re working hard to change that misconception of the profession.”

The patient’s freedom to choose his or her physical therapist is essential to the future of privately-owned practices, Privatera contends.

“Some physicians will tell patients that they need to go to a specific PT office to receive treatment, and sometimes it is because the physician has a financial interest in the physical therapy practice to which he is referring,” Privatera said. “We want people to know that they are free to choose. Just like physicians, physical therapists have different levels or areas of expertise and people need to know they can choose.”

Physicians who own physical therapy practices have justified this on the grounds that it eliminates delays in getting treatment, and that patients will receive better care from therapists that they supervise, Privatera said. However, a June 2010 report by the Medicare Payment Advisory Commission (MedPac) found these justifications largely unfounded and cited potential “conflicts of interest” in physician self-referral.

“Fortunately for us in the Batavia and Rochester areas, there are not a lot of physician-owned practices, but there are at least a dozen in the Buffalo area. It’s a huge problem there,” he said.

Additionally, New York State Workers Compensation regulations have placed burdens upon the physical therapy profession, Privatera indicated.

“The current medical treatment guidelines were intended to eliminate both delays in care for injured workers and costly, unnecessary procedures, but they have had the opposite effect,” he said. “There is additional administrative paperwork and a ‘variance process’ that delays care and keeps people out of work longer than necessary. To make matters worse, NYS has not allowed a fee increase for physical therapists since 1994, although physicians received an increase of 30 percent which coincided with the guidelines implementation.”

As a result, many physicians and physical therapists are opting not to accept workers compensation insurance, leaving injured workers with fewer alternatives to receive health care, Privatera said.

“Our alliance has been active in trying to rectify these issues,” Privatera said, adding that he has met with state legislators, including Steve Hawley, who is a member of the NYS Assembly insurance committee.

Looking ahead, Privatera hopes that increased dialogue will lead to a greater understanding of his profession.

“As the debate surrounding health care reform continues, physical therapists are in a unique position to deliver better, more cost-effective outcomes for musculoskeletal conditions,” he said. “At the end of the day, we’re just hoping to eliminate the barriers which prevent us from doing this.”