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The Insurance Game

August 28, 2016

Healthcare in the US is a hot topic. Without provoking a political or social debate, I want to discuss the way your health insurance is impacting outpatient physical therapy and your musculoskeletal health.
A couple of key points to keep in mind when thinking about health insurance:
You are legally obligated to have health insurance.
Health insurance companies are successful enterprises, the bottom line is the most important aspect of their business.

Healthcare costs rise every year. This is a simple fact of life in the US. Whether you have a major operation, battle a severe illness, or have a completely healthy year, you pay for healthcare coverage. I think we can all understand these facts…coverage costs increase but we have to have it and we should want to have it. The impactful changes in health insurance coverage come down to how we pay. Specifically, changes in premiums (what we pay every month) versus deductibles (what we have to pay out of pocket before insurance begins to cover costs).

Premiums: Between 2005 and 2015, premiums have grown an average of 5 percent each year, compared to 11 percent annually between 1999 and 2005. This is good, rise in premium rate is slowing….
Deductibles: Since 2010, deductibles have risen nearly three times faster than premiums and nearly seven times that of wages and inflation. Not so good.

With rising deductibles, people pay more out of pocket initially. This may be reasonable if you are having major surgery or require significant medical attention on a consistent basis. But for most of us, these events are not the norm, nor are they consistent year in and year out. When we consider that the cost of an average physical therapy stent is near in value to the average deductible, the decision to undergo physical therapy can be clouded due to financial reasons, despite the necessity of treatment. Considering we pay for health insurance, shouldn’t you feel as healthy as possible, whether it be your heart or your hamstring?
Most musculoskeletal injuries can and should be managed conservatively, at least initially. But due to high costs of deductibles, most patients may be reluctant to undergo physical therapy treatment, more frequently due to financial reasons.

Consider also that the most recent 2014 National Healthcare Expenditure report concluded that “Other Professional Services” which includes physical therapy, optometry, podiatry, or chiropractic medicine accounted for approximately three percent of total health insurance expenditures and just over two percent of private health insurance expenditures. “Other professional services” costs approximately $519.3 billion less than Physician Services and $213.3 billion less than Prescription Drug Services.

Another interesting comparison is the total out of pocket expenditures for various services. In 2014, patients paid approximately 10 percent of physician related costs, 15 percent of prescription drug related costs, and nearly 30 percent of “Other Professional Services” costs.

I am not arguing that physical therapy is more important than Physician Services or Prescription Drug Services, I am only highlighting the high cost of these services and differences in insurance expenditures between services.
However, in regards specifically to musculoskeletal health, the increasing utilization of physical therapy services may be part of a more cost effective model. The US Army Medical Facilities, Kaiser Permanente Northern California, and the Department of Veteran Affairs have adopted models that involve physical therapists in the primary care of neuromusculoskeletal disorders. Research is also accumulating to illustrate the cost savings of involving physical therapy in the care of musculoskeletal dysfunction. Focused primarily on low back pain, studies have shown long term outcomes of chronic low back pain are the same when treated conservatively with physical therapy or when managed surgically. Also, recent research done by Fritz and associates, has shown that early referral to physical therapy and referral to physical therapy prior to MRI has shown to significantly decrease long term health costs in treating low back pain.

So what does all this mean for you and your treatment in physical therapy?

– Be proactive. Exercise daily, eat well, and take care of your body.
– Physical therapy is an important part of your musculoskeletal health and overall wellness.
– Do not allow insurance companies to direct your care.
– Most providers are sincerely concerned with your well being.
– Do not allow financial reasons to prevent you from functioning in optimal musculoskeletal health.
– Seek out the best physical therapy practices with direct, hands on, personalized treatment with one on one physical therapist interaction.

Continue to take pride and value in your musculoskeletal health. The paradigm is shifting and with continued emphasis on prevention and wellness from consumers, health insurance companies may begin to see the value in your ability to move well. In the meantime, continue to take care of your body.

National Health Expenditures 2014 Highlights:
National Health Expenditure Accounts: Methodology Paper, 2014:

Physical Therapy Research:

Fritz JM., Brennan GP., Hunter SJ. Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Health Serv Res. 2015 Dec;50(6):1927-40.

Fritz JM1, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012 Dec 1;37(25):2114-21.

Murphy BP., Greathouse D., Matsui I.Primary Care Physical Therapy Practice Models. J Orthop Sports Phys Ther. 2005 (35): 699-702

Wang L, Guo Q, Lu X, Ni B. Surgical versus nonsurgical treatment of chronic low back pain: A meta-analysis based on current evidence. J Back Musculoskelet Rehabil. 2015 Sep 11.

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