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THE PERSPECTIVE

This page illustrates the perspective of the patient and the PT.  Both are affected by the high copay issue that limits the availability of physical therapy.  Although these accounts are ficticional, the story behind them is real.

THE PATIENT PERSPECTIVE

It begins with a shooting pain down my right leg. Over the next several days and weeks, the pain gets worse and tingling begins. Soon the pain becomes so excruciating I can’t get out of bed so I finally make an appointment with my doctor. She tells me I have two choices: I can see an orthopaedic surgeon or neurosurgeon to discuss surgery or, I can go to a physical therapist (PT) and avoid surgery.

So I think about what I want to do. If I go to one of the surgeons to discuss surgery, I have a one-time specialist office visit co-pay of $40.00. But surgery means a long period of recuperation after the operation and, as a single, working mother of three boys, I can’t afford to miss work and be “laid up” for six weeks.

If I choose physical therapy, it involves a combination of techniques to diminish the referred pain from the spine to my leg. The PT will teach me how to do exercises on my own and give me information on how to prevent the condition in the future. I can schedule my visits around my work hours and my kids so I will still be able to work and take care of my children. It seems like a no-brainer.

But here’s the catch: My insurance company applies the specialist co-pay to physical therapy visits just like they do for office visits to surgeons. And since I would need to go three times a week for a month for a total of 12 visits I would have to pay $480 out-of-pocket in a four week period.

What really gets me about this is that my insurance company only allows a maximum of $50 for each visit. That means that if my co-pay is $40.00 the insurance company is only paying $10.00 and I pay the rest! What kind of benefit is that? Aren’t I already paying for this benefit every time I pay my premiums? If I paid $10.00 a visit and the insurance company paid $40.00, then I could afford the treatment I need.

And that’s why I support the legislation supported by the New York Physical Therapy Association to limit co-pay’s for physical therapy services to no more than 20% of the allowable reimbursement. It’s just not fair for insurers to apply specialist co-pay to this service -- it puts the care out of the reach of most people (like me!) and lets the insurance company get away with paying less than twenty-percent for the care.

So I guess until the bill passes I will have to settle on buying an over the counter pain reliever, live with the pain and hope my condition doesn’t get worse.

THE PHYSICAL THERAPIST PERSPECTIVE

One of the most rewarding things about being a physical therapist is when patients’ express their gratitude for helping them return to their normal activities -- pain free -- after they have had a serious issue that caused them pain and limited their ability to move. Every day we see patients who have low back pain or radiating leg pain that is referred from the spine. Every day we carry out treatments that aim to reduce pain, restore movement and teach patients how to treat themselves at home and work.

It is well established that physical therapy is one of the most cost effective treatments for mechanical low back pain and which does not have the side effects that oral medicine, spinal injections or surgery can have. Peer-reviewed research clearly demonstrates that the earlier you access physical therapy the more cost-effective the care and the less likely you will subsequently need expensive diagnostic tests or surgery.

Unfortunately, over the past several years due to actions by insurance companies, many people who suffer from low back pain have, in essence, been denied access to needed physical therapy services because their co-payments can be as high as $40, $50 and $60 per appointment - even though those services are a covered benefit under their insurance plan.

I have been a PT for more than 30 years and during that time I have experienced firsthand the constantly evolving health care system, including significant changes in what insurers cover and how they reimburse for those benefits. Health insurance premiums have skyrocketed over the years and co-payments have risen as well, shifting an ever increasing amount of the cost of care back on the patient. And believe it or not, sometimes the patient’s co-payment exceeds the fee the insurance company pays me for the service! This is particularly offensive since more and more insurance companies encourage their participating physicians to refer their patients to physical therapy instead of recommending more expensive treatments!

I understand that premiums might be lower if co-payments are higher and so that is why an employer chooses the plan. But, what is difficult to accept is that by doing this, insurance companies have totally shifted the burden of payment for physical therapy to the patient Many successful physical therapy treatments are part of a protocol that requires a patient to go to physical therapy 2 or 3 times per week for a total of 8-12 sessions. In today’s difficult economic climate, not many people have a budget that allows them to do this when their co-pay is $40 a visit so they forego the recommended, and much needed care. They end up taking more sick days from their job or they reduce their physical activities because of their pain and develop other health problems as a result.

This situation is unfair to my patients and that is why I support limiting the co-pay for physical therapy to no more 20% of the approved amount. Without this change consumers are being denied access to critical health care services they need.