2004-09-10 / Columnists

Eye On Physical Therapy

By Dr. Tim Rohrs

One of my patients recently reported to me that she thought that my columns were getting a little too “scientific”. I explained to her that it was difficult to come up with topics to talk about and that reporting on current research on pain, therapy and diagnostics were actually much easier to write than personal anecdotes.

With a tip of my hat to “Mary” this column is written with her in mind.

It seems each month and year that passes there are more and more insurance restrictions. As physical therapists, we often caught in the middle between the insurance company and the patient. We are left to explain, or try to explain, to the patient what the insurance company covers and why they make the decisions that they do. Workers compensation cases are notorious for their lack of speed. I have had stories related to me of a person getting injured on the job and not getting the approval for an MRI for close to 8 months. Others have reported that they waited over 15 months for approval for a surgery they needed. Other insurance companies, who shall remain nameless to protect the guilty, offer their insured 16 physical therapy visits a year.

No ifs, ands, or buts.

If the insured hurts their knee in January, gets treated and uses the 16 visits and then fractures their ankle in July, they either pay out of pocket or wait until the following January for therapy to begin.

The most disturbing to me out of all the insurance debacles, is Medicare and how our senior citizens are treated. One of the key points of physical therapy under the Medicare system is that they pay for therapy that is “restorative’” not “maintenance”. Restorative therapy is therapy that will restore the patient to a level of function that they had prior to the current episode of care i.e., hip replacement surgery, fracture, stroke etc. It is not good enough that they are progressing in their therapeutic exercise program. It is not good enough that 4 weeks ago they were lifting 5 lbs and today they are lifting 30 lbs. The improvement must be functional. Are they able to walk a longer period of time or greater distance? Are they able to get out a chair without assistance now? Periodically, I must discontinue therapy with a patient because they are not showing progress under the Medicare guidelines. The patient’s family members call or visit to find out what is going on.

“If my mother does not get therapy, her physical condition will deteriorate rapidly” they say. “He will regress and get weaker”. “If she doesn’t get therapy her balance will get worse and she will fall and break a hip!” “Is this what Medicare wants?

She cannot have therapy to maintain what she has, but will pay for it once she falls, or something tragic happens?”

“Is that what they want?”

According to Medicare regulations; that is exactly what they want.

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