Direct Access and Reimbursement Part II
Reimbursement for Direct Access to physical therapy services
is nothing if not variable and for all intents and purposes, mostly
non-existent. Some states have providers
than cover services without a previous referral, but most do not. This stands in stark contrast to practice
acts, where the majority of states permit patients to physical therapy services
without a referral. So the question
becomes, if it is legal to access therapy services without a referral, why is
this not covered by payors? The answer
to this question lies in complicated political forces, and that some insurance
providers regularly operate outside the realm of reason. That said, we can look at events in New
Jersey to shed some light coverage for Direct Access.
Dr. Robertson, the
author and publisher of this blog has been kind enough to invite me to provide
some commentary on how the efforts now underway in New Jersey relate to
reimbursement in general and Direct Access specifically. As a matter of full disclosure, I am the
current President of the New Jersey Society of Independent Physical Therapists
(NJSIPT) which is the organization currently promoting the legislative efforts
noted above. It should also be noted
that as the invited author of this article that any opinions expressed in this
article are solely mine and do not necessarily represent the opinions of the
NJSIPT.
There is probably no single more complex or controversial
issue in health care than reimbursement and a full treatment of this issue is
not possible in a blog article. That
being said it does deserve continued exposure, exploration and discussion and
that is the spirit in which I am approaching this topic.
The complexities of reimbursement arise from an abyss of the
highly varied payer policies of profit driven commercial payers, a heavily
regulated Medicare program, the compendium of state regulations regarding
provision and payment for services and an entire medical industry struggling to
survive in a competitive environment where margins are extraordinarily thin or
non-existent.
As a practicing clinician and private practitioner it is
from the perspective of standards by which I view these legislative
efforts. As the healthcare industry has
consolidated, there has been a concomitant decline in reimbursement as the
insurers increased their stranglehold on the marketplace. Despite this, healthcare costs for
musculoskeletal care have steadily increased. Over the past few years as draconian cuts in reimbursement approaching
60% have put my colleagues and I on the verge of financial collapse, it became
evident that a severe conflict had developed pitting compliance with practice
standards at direct odds with remaining financially viable. The question was how to rectify this
imbalance. The answer was legislatively. This was confirmed at a recent legislative
committee hearing where a member of the committee commented that it was the
purpose of the legislature to ensure fairness when one party utilizes its
position to the detriment of others.
In short this legislative effort in NJ seeks to ensure that
providers are compensated fairly based on prevailing fees as determined by the
state, that barriers to access are removed by ensuring that third party payers
pay for medically necessary services when sought by consumers without a prior
referral from a physician and that payers pay providers their share of the
liability directly without regard for network participation status.
Although there is great variability as to what
“Direct Access” means depending on the various state practice acts and other
statutes, as previously mentioned in this blog by Dr. Robertson one of the
greatest barriers to the actualization of “Direct Access” to Physical
Therapists is the lack of coverage by third party carriers. The legislation currently pending in New
Jersey provides for the coverage of Physical Therapists’ services when accessed
directly by consumers. Considering the
mounting evidence that medical costs are reduced when Physical Therapists’
services are accessed directly I am certain that all interested parties will
realize benefit from this legislation including the third party payer
community.
Mark F. Schwall, PT
- Direct Access: An Overview
- Direct Access: Is it safe?
- Direct Access: Reimbursement, also see Part II
- Direct Access: The Netherlands
- Direct Access: Making it Work
- Direct Access: The Future
Direct Access: Reimbursement
The entire concept of reimbursement for healthcare services is vast and complicated. But, examining costs for healthcare is not so complicated. Certain services are expensive, others less so. For example, orthopaedic surgeons are expensive with certain procedures like spinal fusion costing $40,000 or more. Pharmaceuticals, which are the tool of choice in primary care, and needless radiological imaging are also expensive. Very few of these expensive items are effective, yet reimbursement for them is provided all the time.
Conversely, direct access to physical therapists is not expensive and can produce outcomes superior to the expensive options noted above, yet coverage for this by payors is rare. When it does occur, costs go down.
Yet reimbursement for direct access to physical therapists is rare, despite a large transition of state practice acts to allow for this. Some in the profession think it is a matter of time before payers realize the potential savings and alter their policy, others are taking a more active approach through the legislature. Up next, a guest post furthering this discussion of reimbursement for direct access.
- Direct Access: An Overview
- Direct Access: Is it safe?
- Direct Access: Reimbursement, also see Part II
- Direct Access: The Netherlands
- Direct Access: Making it Work
- Direct Access: The Future
Image by TWCollins
Meetings Be Gone
I’m taking a couple days off from work to ride mountain bike on the most awesome FATS trail system here in SC. I’m really looking forward to it before the fall semester begins. The last thing I did at work before I left was to sit in a meeting. It was a typical meeting. As someone who likes speed and excitement rather than laborious discussion, meetings are not my best friend.
So, for all my friends in academia in particular and others who are subject to mind-numbing meetings, here are a couple links to ponder:
Do Meeting Make Us Dumber? [via Lifehacker.com]
Shorten Meetings by Standing Up. [via Lifehacker.com]
The Meeting Miser calculates the real cost of meetings based on pay scale. (And we wonder why education is so expensive!) I calculated that my meeting yesterday cost over $300 for my institution!
5 Alternatives to Meetings. This one is my favorite, of course!
Here’s a cool video of the Brown Wave Trail at FATS. Way better than meetings!
Research Methodology: Media Style
Of course you all know by now that scientists have put exercise into a pill.
This is yet another example of ridiculous interpretation of science by the media. The pill was tested in a mouse! Humans are not mice. Exercise and it’s benefits are extremely complex and multifaceted. The media is going completely bonkers over this very catchy headline. Geez, even the local news in market 115 picked it up last night!
I read the paper and the researchers end it with:
"We believe that the strategy of reorganizing the preset genetic imprint
of muscle (as well as other tissues) with exercise mimetic drugs has
therapeutic potential in treating certain muscle diseases such as
wasting and frailty as well as obesity where exercise is known to be
beneficial."
The might have added:
"Our results should be interpreted cautiously as animal models do not necessarily translate to humans, and the safety and long term effects of these substances have not been evaluated…not even in mice!"
The researches haven’t done much to add caution to the conversation.
“It’s a little bit like a free lunch without the calories,” said Dr. Ronald M. Evans, leader of the Salk group."
I can only image what’s next.
So did my friend Rachael. Here are her upcoming headline suggestions: ‘Pop a pill for a six pack’; ‘NHS saves millions by replacing physios
with a pill’; ‘Health clubs face bankruptcy’; ‘Sudden rise in heart
failure’; ‘Couch potato wins marathon with no training!’
Yikes. This is the last thing we need.
Finally, from the WSJ article linked above:
If the medicine "results in better-looking people, that would be good,"
said comedian Fran Lebowitz. "All I have right now is a vision of slim,
vain, lazy mice."
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