The Current State of Physical Therapy

an opinion piece

I graduated during the lockdown - December 2020. I never wore a graduation cap and gown, and I was so eager to start working that I literally worked in November 2020 as a marketer and never got paid. 

I immediately went into fellowship, became a director, and it didn’t take long to learn about physical therapy and the healthcare system. 

I had a great job at a private practice who truly cared about results, but even when they care, it was still affected by the umbrella of insurance-based healthcare.

This wasn’t specifically where I was working at that clinic, this was the case with physical therapy. 

I even worked somewhere where the owner told me after a couple weeks to do treatments that could be reproduced by physical therapy assistants, and to stop getting patients better too quickly. 

You see, in an insurance based model, insurance pays based off of time spent with a patient. There is something in physical therapy called an 8-minute rule. If a treatment is 7 minutes - insurance doesn’t pay. So that’s why your treadmill is always an “8 minute warm-up.” Anything from 8-22 minutes, is considered “one unit.” Then it goes up in 15 minute increments, plus or minus 7. Attached is a chart to make sense of this dumb rule:

If this isn’t stupid enough, different treatments have different reimbursements, such as manual therapy (97140), therapeutic activities (97530), therapeutic exercise (97110), neuromuscular re-education (97112), or gait training (97116).

Now I wasn’t intending on this blog post being a lesson on physical therapy billing, but this is really the problem. It’s not based off of outcomes, not based off what the patient needs, but just what insurance pays for. Also, notice I didn’t mention dry needling. It has a code (20561), but it doesn’t have a reimbursement by most insurers. And therein lies the problem. 

It’s not secret that I’m a fan of dry needling. The research supports it, patients have great outcomes, I teach the class. That being said, every treatment has its place. I don’t use therapeutic ultrasound (97035, the only code I didn’t have in my long-term memory), but it still has a place in rehab. Well, the code for dry needling has no reimbursement, so that is why so many practices don’t provide this as a treatment. Another thing that practices may do is find a work around with billing, in order to bill your insurance company. They do this by billing dry needling, manual therapy, and electrical stimulation all at once. In my strong opinion, this is fraud.

The point is, outcomes are what should matter - not what we actually did in treatment. My patients pay me directly for results. No middle man. insurance should be the same. Results are what patients are looking for. 

If insurance bases things off of time, you can’t act like it doesn’t dictate treatment. 

And by my understanding, medicine isn’t off the hook. Physicians make money predominantly off of performing a treatment - injections, surgeries. Office visits don’t get reimbursed very much, so providers are sort of incentivized to do some form of treatment. That is why they often refer to physical therapy, and will do a cortisone injection. 

This is not trying to be confrontational, it is more of pointing out the faults of the healthcare system from my perspective. This is one big reason why physical therapy looks like it does. 

Add to that a paradox. Physical therapists who are new grads get paid less, and typically take more treatments to get somebody better. For that reason, they see patients for more treatments and more time. 

Specialty physical therapists, namely fellows of orthopedics, get better outcomes. Time wasn’t a factor in this study, but you can only imagine that they can get somebody better in fewer sessions. Specialists also get paid $20-25k more per year. 

“So you’re telling me that big companies can hire new grads, pay them less, and make more money? That means I stay in treatment for longer and get a worser outcome,” says the voice in my head.

Damn right. That’s the current state of the profession. 

So find somebody good. Do your research. Ask around. If you’re not getting an outcome, find somewhere that you will. You are in control of your own life, and you only get one body. 

I just paid $1,600 for new tires on my wife’s car. It was a lot of money, but I knew I had to do it for her and my children’s safety. I purposely paid extra for the better rated tires. You get what you pay for. Whether that is tires, or healthcare.