CME-MOC

Time Stamps

  • 01:55 Fall Prevention and Mobility 
  • 07:47 Documentation
  • 14:35 Outpatient PT 
  • 18:14 Durable Medical Equipment
  • 22:55 Reimbursement

Show Notes

Pearl 1: Don’t forget to mobilize your inpatients

  • During a hospitalization for an acute illness, the majority of patients remain limited to a bed or chair and ambulation occurs infrequently
  • Low mobility of older patients in the hospital setting can lead to reduced future functional status and loss of muscle mass
  • Even patients that had no contraindications to mobility in the hospital and were completely independent prior to admission spent a small amount of time on their feet
  • Commonly perceived barriers to mobility include patient symptoms, restraining medical devices such as catheters and intravenous lines, and concern from patients and providers about falls
  • Continue to assess your patient’s functional status daily during hospitalization
    • Instruct patients to get out of bed and try transferring to their chair or ambulating
    • Continue to assess the necessity of barriers such as catheters and lines
    • Utilize ancillary staff to help mobilize patients and encourage them to do so
    • Sometimes all it takes is to simply inquire, “have you been out of bed today?”

Pearl 2: Tips on effective documentation 

  • Start by describing the patient’s baseline mobility level
    • How far could they walk?
    • Did they require any sort of assistive device?
    • Were they walking around only inside their house or around their community as well?
    • Do they require another person’s help to get around or are they independent?
    • Other diagnoses that may relate to ambulatory problems 
    • Symptoms that limit their ambulation
  • Documenting a patient’s change in functional status from admission in their discharge summaries is often neglected but very useful information for other providers and physical therapists when the patient follows up as an outpatient. 
  • Some hospitals may discourage physical therapists from recommending site specific patient dispositions to allow for more leeway for the discharge planners

Pearl 3: Don’t be afraid to escalate a patient’s physical therapy

  • If a patient didn’t achieve the desired improvements in their functional status after their first few sessions of physical therapy it doesn’t mean that further physical therapy shouldn’t be pursued
  • Patients may need additional more intensive physical therapy sessions or a different type of therapy all together 
  • There are a lot of different types of physical therapy specialists that are underrecognized
  • Referral to physical therapy subspecialists may be beneficial for some patients. The American Board of Physical Therapy Specialties (ABPTS) offers board-certification in nine specialty areas of physical therapy: Cardiovascular and Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, and Women’s Health.

Pearl 4: Tips on ordering durable medical equipment

  • Examples of durable medical equipment (DME) include but aren’t limited to wheelchairs, walkers, hospital beds, power scooters, portable oxygen equipment, orthotics, and prosthetics
  • Medicare will typically only cover 80% of the cost of DME so patients have to pay the other 20% which can become a financial barrier, typically applies when a patient needs a change in their DME (e.g upgrading from a cane to walker)
  • If the patient simply needs to replace old or worn DME Medicare only pays for a replacement every 5 years
  • Medicare does not cover:
    • Equipment mainly intended to help you outside the home
    • Most items intended only to make things more convenient or comfortable. This includes stairway elevators, grab bars, air conditioners, and bathtub and toilet seats
    • Modifications to your home, such as ramps or widened doors
  • Rolling walkers are a good choice for patients with cardiopulmonary conditions because it allows them to brace themselves on their walker for a rest break if needed
  • If you are in a skilled nursing facility (SNF) or are a hospital inpatient, DME is covered under Medicare Part A. Otherwise, it is covered under Part B
  • It is important to document medical necessity when prescribing DME by documenting symptoms that limit ambulation, current assistive devices, or reasons why their current devices aren’t effective in assisting with their ability to perform ADLs.
  • Power Mobility Devices (PMD), which includes power scooters and power wheelchairs, are covered under the Medicare Part B Durable Medical Equipment benefit. 
    • To qualify for a PMD:
      • The patient must have a mobility limitation that significantly impairs his or her ability to participate in one or more Mobility-Related Activities of Daily Living (MRADLs) in customary locations in the home
      • The patient can’t use cane or walker 
      • The patient does not have enough upper extremity function for a normal wheelchair

Pearl 5: Tidbits about physical therapy reimbursement

  • Medicare Part A covers inpatient hospital and skilled nursing facility care, home health care, hospice care, inpatient rehabilitation, hospice
  • Medicare Part B helps pay for medically necessary outpatient physical therapy.  This covers 80% of the Medicare-approved amount. When patients receive services from a participating provider, they pay a 20% coinsurance after meeting the part Medicare Part B deductible ($198 in 2020).
  • Prior to September 2019 skilled nursing facilities were reimbursed based on the volume of services provided, in October 2019 CMS implemented the Patient Driven Payment Model which removed this financial incentive to provide a higher volume of therapy and reimburse based on a comprehensive assessment of patient needs
  • This shift to the PDPM model caused some for-profit nursing homes to maintain profits by scaling back on therapy hours and number of therapists which could impact patient outcomes down the road
  •  

Transcript

Walton-Mouw: There’s so much that we as the health system can do, we as physical therapists can do. And we as the interprofessional team can do, you know, and it is sad to say, but you know, there’s so much that we can do to better their care but also to prevent their decline. That, that, that’s what drives me.

S: That’s Dr. Rachael Walton-Mouw, physical therapist in geriatric rehab at Grady Hospital. She hits the nail on the head in thinking about how there’s more we can do as teams to prevent the physical decline of our patients. 

But as I’ve pointed out in other interprofessional episodes, in the hustle bustle of the clinic and hospital, we barely get to talk more with our PT colleagues about how we can work better as teams 

And that brings us  to Episode 4 of our Interprofessional Series with the American College of Physicians focusing on learning from physical therapy experts. You can get CME credit for this episode with a link in our show notes.  I’m Dr. Shreya Trivedi, a general internist at BIDMC.  I am joined by Dr. Chris Tan, a 3rd year medicine resident at Baylor Scott and White

C: Thanks for having me on! I learned a ton and implemented a bunch of things I do differently now.

S: We learned a bunch of a practical nuggets and to our surprise, we also learned a lot of WHY things are the way there — where did this pervasive, fear of patients falling come from 

C: to why sometimes PT document the way they do

S: to why some of our requests of durable medical equipment get denied

C: and lastly why even though we are sending patients to rehab, patients are often getting less and less rehab. 

S: And with that, welcome to Core IM, let’s get started. 

1. As a healthcare system there is a “fear of falling” that needs to be overcome so that we can begin to mobilize our patients appropriately

S: So in the inpatient side of things it’s a pretty common mentality to think oh these patients are sick, let them get rest, we don’t want them to fall but our physical therapist colleagues pointed out that mentality may be doing more harm to our patients

Walton Mouw: From a health system standpoint don’t assume that every patient when they get out of bed is going to fall. I think we’ve put a lot of fear on our nursing staff, on our health system and in our patients. We kind of paralyze them with that fear that they’re gonna fall when they get out of bed instead of saying, Hey, what can you do? Not look at what can’t you do?

S: So we clearly want the best for our patients but why are we so afraid of our patients falling? It seems like every patient has one of those bright colored “fall risk” bands on their arm 

Walton-Mouw: I really blame Medicare because in 2008, they put a financial burden on hospitals. When a patient would fall while inpatient and have an injury, then Medicare would put a financial burden on that hospital. So hospitals really got afraid and worked diligently to have these fall prevention programs. Unfortunately, what’s happened is that we’ve implemented these fall prevention programs and looked for, you know, reasons why they may fall.I think someone said we’re killing them with kindness. I mean we’re making them weaker, we’re making them more at risk of falls.

S: It’s eye-opening to think about a single policy’s downstream effects — and in particular how have these financial penalties for falls-have impacted the frontline staff in the hospital.

Walton-Mouw: That whole mindset, the impact of, of fall prevention programs on a nurse’s perceived workload. A bed alarm goes off and everybody has to run to that bed. And, they’re afraid of their job. They’re afraid of getting called out the zero days since the last fall on the wall be in that unit — being THAT unit. 

S: Yeah you don’t want to be THAT unit. And that aspect of medicine pains me – the things we do to make metrics look good but whats swept under the rug is the workload or stress on frontline staff that it took to get to those pretty powerpoint bar graphs! And it’s even more eye-opening to think how hospitals avoiding financial penalties have actually impacted the patients it cares for. 

Gorman: That’s what’s really scary because you put a few of these older patients who have a lot of comorbidities on even just a few days of bedrest and the amount of muscle mass that they lose and the function that they lose even in a really short period of time can make the difference between them going home with a family member or some in home support versus now they have to spend a week or two in a skilled nursing facility.

S: That’s Dr. Sharon Gorman, a professor of physical therapy at Samuel Merritt and also works inpatient at Kaiser Health.

Gorman: Most patients after a little while, the thing that will kill you is laying in bed. You’re going to get a bed sore, you’re going to get a DVT, you’re going to get pneumonia, you’re going to get debilitated. I think every piece of evidence that we’ve discovered is that we over rest people, especially people who maybe are older and are more at risk of developing very quickly, a lot of problems with moving around. And I get it. I fight it every day. Oh, but, but she’s sick. You need to let her rest. And it’s like actually rest is probably the thing that will kill her. 

S: And when we look what contributes to that thinking from the clinician side, sometimes  “catheters and intravenous lines” are misperceived to be reasons patients can get out of bed, which is not the case– and surprisingly, even for our functionally independent patients not hooked up to anything get mixed messaging on mobility in the hospital too.

Gorman: They did this great study in Australia where they looked at people who had no contraindications for mobility in the hospital who were admitted, who were completely independent before they came to the hospital and they only spent 45 minutes on their feet during the day during the four days they monitored them. There was no reason these people weren’t getting up. The number one reason patients cited that they said they didn’t get out of bed was nobody told them they could.

S: Now that I hear it, that study makes so much sense and perhaps I was just assuming “Oh, my patients knew they could get up and move around in the hallway,” but these assumptions are clearly an oversight on our part. 

C: Or we think oh they have “PT on board” so they’ll get their exercise in.

S: I’ve thought that too but realistically, they don’t always get seen by PT and as we will talk about later, PT is also stretched thin for time. So there’s gotta be some actionable steps we all can take.

Walton-Mouw: Changing the health system, helping the nurses feel more comfortable moving patients, the nurses and the nursing assistants and the physicians. I mean, we have talks with the physicians and say, you know, this is how you watch somebody stand up. This is what we’re looking for. Um, you know, all of that. We’re all going in there and saying, have you been out of bed today? Great, you have! Not, “don’t get out of bed cause you’re gonna fall.” So, you know, if we all had that mindset of “we expect you to get out of bed, we want you out of bed, we’re going to help you get out of bed.”

S: That’s exactly what I’m take away for next time I am on floors — If I don’t have the power to change policy or penalties that hospital get dinged for, at least be more mindful about asking our patient about getting out of bed, encouraging movement that is safe for them and educating patients hey laying in bed all day, you’re going to get weaker, lose muscle lying in bed all day and let’s try to prevent some complications 

2. Pertinent and effective documentation from the rest of the healthcare team helps physical therapists tremendously

C: Another thing that comes up on the wards, and even in clinic, is documentation — those notes can feel tedious for everyone, but what we learned from our physical therapist colleagues was that WHAT we documentation can really impact our patient’s care

Gorman: Concrete example. I’d say like getting that really good idea of what baseline mobility was like. And when was that? Like are we talking about three months ago because somebody has been declining slowly. Are we talking about a week ago when this started? Like what is the baseline and what were they functioning at at that level? Were they independent? Did they need help? Did they use any kind of device? Were they using a cane or a walker? And then for like things like ambulation were they just walking inside the house or were they able to actually walk in the community as well? Those are really, if you can get those kind of nailed down that really helps build a picture of, “Oh three months ago this person was walking independently, in the community without a device and over the last three months up until when they were admitted yesterday, now is completely dependent, can’t stand up, is totally unable to get out of bed by themselves.”

C: And yes, while our physical therapy colleagues will help us gather this information, understanding and documenting the patient’s functional status in the EMR in multiple places can go long way with things not getting lost in charts.

Falvey: Physical therapists are often the only people that measure functional status in primary care or in the hospital setting really. Um, and that information isn’t often communicated well across the continuum. So physicians don’t often include functional information in discharge summaries from the hospital.  

C: That’s Dr. Jason Falvey, a geriatric physical therapist and postdoctoral fellow at the Yale school of medicine. To put what he is saying into context, one study found 4 in 5 discharge summaries did NOT  have the patient’s functional status compared to baseline and  things such as the need for assistive devices or future PT needs  were completely missing from half of the discharge summaries.

Falvey: It’s often not in primary care or follow up notes from your primary care physician visits. So, one of the issues that arises is physical therapists often are seeing patients without really any context of their prior level of function and prior measurements. And it’s really difficult to kind of prognosticate. So I think if I’m going to extend the challenge to all of our interdisciplinary colleagues, it’s kind of, you know, be like therapists in the way that function is kind of a central part of measurements that you take during visits or are always asking about it.

C: Challenge accepted! And I still remember the few times that I’ve been admitting a patient and there was actually clear documentation of the functional status in the outpatient setting or in prior discharge summary… that information was gold! 

S: You know we trend Cr, Hg all the time – its knee-jerk part of our patient presentation but we are not good about trending their functional status – and now that I think about it, id argue that change in a patient’s functional status from last year to this year is way more important than their small Cr bump.

C: That’s a good point and we just gotta get into the habit of documenting the functional status and its changes over time, especially because prior PT notes can get easily lost  in the chart. And the few times I do get a chance to dig into the chart and look at a prior PT note, I gotta be honest sometimes the PT notes, at least the ones I have seen, are sometimes hard to interpret.

S: Yeah I’m sure they feel the same looking at our lengthy notes too with out acronyms and medical jargon. But, yeah the PT notes have I’ve seen have all these tables of different movements and numbers and I’m not sure what the numbers mean and I’m probably being swamped paged at the same time and what I usually end up doing is just scroll down to see what they’re recommending for disposition.

C: Yeah I do the same but sometimes, it can be hard to interpret even those disposition recommendations — sometimes I feel like it’s in coded language. Luckily, our physical therapist colleagues are here to share their perspective of what’s going on behind the scenes

Gorman: They’re trying to get us away from recommending site-kind of specific things they’re trying to get into and it ends up just being all this coded language that means the same thing, which is a little frustrating. I’ll just own that. That’s because we’ve been told don’t say the level of facility because that gets the discharge planners into issues potentially. It gives them a little more flexibility depending on availability of beds and what people’s insurance says

C: Okay that;s really helpful to know! So it may not be PTs choice to NOT write the precise place they recommend but they have to write their notes in a certain way to let the discharge planners have more options on where the patient goes. 

S:  I’m all about options for our patients! So I get that, I get that. But sometimes it’s still sometimes vague language like recommend “intermittent therapy.” What does that really mean? Technically isn’t it intermittent therapy everywhere? 

Gorman: We talk about intermittent therapy and that either means outpatient or home health and frequent therapy means you know, skilled nursing facility and frequent therapy with rehab means acute rehab and everyone’s kind of got their own little lingo and I would say that’s a good one to just go to your rehab department and go, what do you mean when you write this? I just had that discussion today with a doctor who called me about my patient, he was like “so you’re recommending…” and I go “intermittent therapy”. He goes, so you mean home health? And I was like, yeah, I’m not typing that but I’ll tell you on the phone that’s what I mean.

C: So my take away from talking to the physical therapist is yes, documentation can feel soul crushing at times and there are reasons beyond their control of why they have to document in a certain way they do and convo with your local physical therapist with the lingo they use, can go a long way. And on our documentation end, we may sometimes neglect to mention their functional status on discharge but this information can be a gamechanger for the next practitioner who sees them in the outpatient setting or unfortunately if they readmitted

S: And I’ve actually changed my own notes or asked my teams to just put their functional status their one liners — for me, hearing a presentation of a 63M who was previously walking 1 mile daily with a cane with a hx of a prior MI presenting with SOB is very different from a 63M who is primarily homebound with a HHA assistance x 3 days/week with a hx of a prior MI presenting with SOB. Clues me in right away how far away the patient is from their functional status and what may be realistic goals I am working towards for their discharge.

3. Reporting that patient’s failed physical therapy too soon

S: Let’s shift fully to the outpatient setting. I think we have all seen patients in the clinic with back pain or some other ache who we sent to physical therapy and they come back to they’re still not better – can we say that the patient failed physical therapy?

Falvey: There’s a misconception that we are ordering physical therapy or a patient “failed physical therapy” without really defining what that means. So when I would never send somebody to the doctor and then have them not get better and say that they “failed medicine”, they didn’t fail the medicine. They just, you know, didn’t get better from that one particular intervention or that one particular drug that was tried for hypertension. Maybe you have to try a different one. Um, so similarly for physical therapy, you know, if a patient goes to therapy and quote unquote “fails therapy”, really ask some probing questions. Like, what were they doing, what kinds of activities were not successful?

S: Those probing questions or even asking about adherence to doing the exercises at home can help us understand why the patient may still be in pain. So we may be doing our patients a disservice by prematurely saying therapy didn’t work or another possibility is that we did not explore all of their available physical therapy options.

Falvey: Because there’s a lot of different interventions that physical therapists prescribe. So if a patient is having falls or dizziness or balance issues and they’re sent to therapy and they work on their balance problems and they’re still dizzy, it doesn’t mean that they failed therapy. It might mean that they need a different type of therapy. So maybe that person goes to vestibular rehabilitation and they have positional vertigo or they have some sort of vestibular issue from a concussion that is really causing some of those issues and balance exercises weren’t the appropriate intervention. So I asked clinicians to really, that terminology is hard for patients because that also makes them think that physical therapy is kind of a one size fits all, that therapists all kind of do the same thing are over kind of technicians. And I think there’s a lot more, especially at the expert level for therapists that go on… so it might be important to identify those therapists in your community for, you know that are geriatric focus that really do more balanced falls neuro, that’s a very different brand of therapist than does does orthopedic issues are a very different brand than people who are experts in home care or cardiopulmonary specialities. 

S: Before this, I thought all physical therapist are the same but just like in internal medicine has different subspecialties, physical therapist also have expertise in different areas.

Falvey: I mean there’s seven recognized board specialties in physical therapy. So there’s a lot of factions of therapy that are maybe a little bit under-recognized publicly.

S: Under-recognized indeed! And I can see how finding and building that network of local physical therapy specialists can be super helpful for patients with more challenging issues. So my takeaway from this is that patients might require longer treatment courses of physical therapy or may need longer treatment courses. We may need to explore a different or more specialized type of therapy all together. And avoid saying “failed physical therapy!” and passing that jargon in the chart without probing questions that really justify that.

4. Ordering the correct durable medical equipment (DME) for a patient can be confusing and PTs want to help

C: So, let’s say you see a patient who comes into the office using some durable medical equipment, also known as DME to get around, how do you know if what they are using is appropriate for that patient?

Falvey: I kind of used a rule of thumb, if they are using more than 25% of their weight and that’s kind of a subjective judgment, but they’re leaning pretty heavily on a cane. You know, I usually suggest something a little bit more restrictive like a walker. Rolling walkers generally are great for people who, you know, need that short rest break. So that might be your chronic cardiopulmonary conditions. Rolling walkers are great for them. COPD and CHF, because one, they’re leaning forward on that walker, so they’re able to kind of brace themselves and use those accessory muscles for breathing, and dyspnea relief, which is a really valuable tool for them as well as being able to lock it up and sit on that seat and be able to take those short little breaks.

C: I appreciate that rule of thumb if they’re using 25% of their weight, it may be time to upgrade to say a rolling walker that gives them more support — but some of the equipment can get really fancy. So, who pays for these pieces of equipment? 

Falvey: Medicare typically pays for an assistive device every year. So, that’s really important to keep in mind because if you encourage a patient and prescribe a cane and then they bill it to their insurance company, that is the only piece of equipment that they need. And if it’s not the appropriate piece, you, you know, for an entire year they’re paying out of pocket for any other mobility related pieces of equipment that they need.

Medicare only pays 80% of any of them as well. So patients are really on the hook for 20% of the cost of any of these things. So there is a socioeconomic burden associated with some of these devices too for patients who don’t have a supplemental payer or supplemental Medicaid insurance. Um, so then there are other considerations too that often patients are maybe unaware of until they get that bill

C: Honestly…That makes the two of us- even as the prescribing doctor it’s hard to know what gets covered and how much things cost. For ex. medicare doesn’t cover most items that make things more convenient or comfortable. This includes things like stairway elevators, grab bars, toilet seats or ramps. 

S: And even on top of that when we are able to help our patients get DME items approved, it all seems to circle back to our favorite thing…documentation.

C: And to hammer that home, CMS found that about half ($46.3%) the time a payment might not go through for example on power wheelchairs  was because of things like medical necessity weren’t documented properly 

Gorman: Some of the time for physical therapy, it’s really how you document stuff and how specific you are about the person’s deficits and what they can and what they can’t do and how that affects things that make them safe or not safe. That can help you get equipment or more visits.

C: Some common pitfalls that we may neglect include things like documenting the patient’s symptoms that limit ambulation, why their current assistive devices aren’t working and their inability to perform their ADLs in their current home setting.

S: So, for example, documentation for a power wheelchair must reflect that the patient is unable to be mobile in their home situation (home or otherwise) without a powered device AND that another ‘less assistive’ device like a cane or walker will NOT work.

C: So, to recap, basically medicare can pay for equipment once year. So if you’re going to prescribe, make sure it’s appropriate for your patient, OR ask you PT colleagues for help. But either way, if you prescribing the equipment, the takeaway is to be mindful  about documenting the medical necessity to save you from some pesky phone calls later.

S: And after doing some research, much to our chagrin, say your patient has a broken wheel on their wheelchair and needs to be replace the same type equipment, it’s actually only covered once every 5 years.

C: But either way if you prescribing the equipment, the takeaway is to be mindful  about documenting the medical necessity to save you from some pesky phone calls later.

S: And if you don’t feel like fighting with insurance and if your patient can afford, it might just be easier to have your patient order medical equipment on amazon or some other online equipment site.

5. Restructuring of physical therapy payment models has led to reimbursement woes

S: The last thing we spoke to our physical therapists about was how many times our patients have complained that their rehab stay to get “stronger” actually had very limited rehab. And there are policy reasons as to why. 

Falvey: I think as a therapist we constantly are fighting reimbursement struggles. 

C: So back in the day, all the way back to before 2019, skilled nursing facilities got reimbursed by the volume of services so they basically had autonomy to charge in tiers based on the total therapy time per week they delivered. 

S: So the more therapy a patient got, the more the facility got reimbursed. So rehabs had a pretty nice incentive to have more hours of physical therapy.

Falvey: It gave the skilled nursing facility a higher payment which was a blessing and a curse, but really did, you know, kind of nursing facilities highlighted the value of therapy and really invested in their therapy staff. 

C: The curse was that this old model gave nursing homes a financial incentive to prioritize the amount of physical therapy over medical necessity. CMS did not like that and moved to a new model in October 2019 where reimbursement is based on a comprehensive evaluation of patient needs — which sounds great on paper but it’s a lot messier in real life.

Falvey: And the payment change recently came and really started paying based on patient complexity, kind of as  an overall bundle model, which generally is, um, a good thing. But for, for therapists that really disincentivized nursing homes from providing therapy. And so most nursing homes responded by decreasing the amount of therapy that patients got, um, without really any idea of how that was going to impact outcomes.

C: What really helped me understand this was thinking about it from the prospective as if I was running a for-profit nursing home ‘

S: Yeah so you can’t just bill anymore for more hours of therapy  and now you get a set amount of money for a patient’s diagnosis and complexity so what are you gonna do?

C: So I’m gonna try to save money where I can and thats exactly what happened. So unfortunately, this led to a lot nursing homes starting laying off therapy staff or do group physical therapy when what they need individual therapy. 

Falvey: So now a skilled nursing facility won’t get paid as much for providing 720 minutes of therapy. So the immediate result has been to reduce the amount of therapy provided because it’s not profitable anymore. So a patient with a stroke, a patient with a stroke may receive, you know, may have been receiving two hours of therapy per day and may now only be receiving 30 to 45 minutes per day. Um, and in some facilities we’re hearing anecdotal reports, that thats happening. Similarly in home care agencies, you know, the number of visits that are really incentivized to cover are starting to decrease.

C: That is so disheartening — this is what happens if we put profit before patients. And I can’t even imagine how frustrating it might have been for a physical therapist to have so many third parties interfering with their practice 

Walton-Mouw: We’ve kind of allowed ourselves to, um, be managed where we’ve been such in a model of being reimbursed by insurance. That’s why the productivity is being pushed on us is because the reimbursement rates are declining. I can provide beautiful health care, physical therapy to this patient who then thinks it’s great value, but they’re not the ones that associate a payment or a cost to that value. It’s a third party.

C: And the impact of insurance paying less is similar to what we experience in primary care where we have to pack in as many patients as possible in a day — we all know the disservice that jam-packed days do for our patients as well for us on the frontlines.

S: And the buck doesn’t just stop there. Insurance reimbursements aren’t just driving the volume of patients PTs need to see in day but also how many times they can even see an individual patient.

Gorman: It can be really difficult and I’m sure it’s just like what you guys experienced, really frustrating where you know an insurance company decides off the bat that somebody only gets so many visits and you’re like, what do you mean you didn’t even ask me what I thought before? You already said how many visits and now I’m going to have to write a letter and spend how many hours on the phone talking to people to try and get more visits for my patient. In the outpatient world, is probably one of the most frustrating and burnout related items that PTs deal with is this whole, Oh, their diagnosis is this, so they only get this much care. Which, especially for PT, like I see patients with all kinds of diagnoses. It does not matter what your diagnosis is. It’s a how are you not able to move and if you don’t have that information, why are you telling me how many visits I have to get somebody better? Because I can have somebody with COPD who I think only needs three visits and I can have another person with COPD who I think needs 12 or 15 visits because COPD is giant and it’s not like one thing and it’s how is it affecting your function as a person with COPD.

C: That’s a perspective that I hadn’t heard. It’s bizarre the # of PT visits a patient gets in the outpatient setting is determined by the diagnosis like back pain. But we all know two people’s back pain is not the same .

S: I hope this episode motivates more people to get involved in policy and leadership and it’s crazy how much that trickles down! What i’m taking away is the next time I have a patient who complains about a experience at rehab and how little rehab they had, i at least have a deeper understanding of why and maybe I won’t try to sell the whole “going to rehab to get stronger and getting much more physical therapy” when it might not be the case. And the other thing I’m going to take away is to have more empathy for our physical therapy colleagues who seem like they are also under the pressure for productivity in clinical care.

S: And with that’s a wrap for todays episode. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! 

If you want to add any of your own tips or share challenges, tweet us and leave a comment on our website page, on instagram or facebook page Thank you to Dr. Cathy Cichon  for the accompanying graphic, to Solon Kelleher for audio editing, to peer reviewers physical therapist Kim Levenhagen and Jennifer Ryan and thanks to you!  

As always we love hearing feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions. 

References

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