It’s no secret the US Healthcare system has a spending problem. Musculoskeletal issues account for a large percentage of this with neck and back pain being some of the top spenders. It’s also no secret the US healthcare system has a primary care problem. There’s not enough of them, their schedules are packed, and on a daily basis deal with high administrative burden. A significant percentage of these visits PCPs are slammed with everyday are for musculoskeletal complaints.
Given these two facts it starts to beg the question: Is there a way to decrease the cost of musculoskeletal disorders and lighten the load of PCPs? Why yes, actually, there is. The answer? You guessed it, primary care PT. With 20 states now offering unrestricted access and 28 with provisional access that varies WIDELY between states, primary care PT is starting to become more of a reality.
Current research is already supportive of PT’s in a primary care role. European countries such as the UK and Sweden also have a general practitioner shortage. They’ve begun using primary care PT to offset the burden with positive results in outcomes and reduced healthcare costs. A US-based lit review by Hon and colleagues also found direct access PT led to more cost-effective care and better functional outcomes.
So with primary care PT, not only does the patient not need a PCP visit, but also less imaging, injections and surgeries. I believe many of us know these things. Some of it is common sense, but I think the financial benefits of primary care PT could go far beyond musculoskeletal conditions. Primary care PT could create a much wider, more significant, butterfly effect across the healthcare system.
The Butterfly Effect
It’s a common complaint from patients that they’re not getting enough time with their doctors, especially their PCPs. Based on my brief Google searches, it appears doctors spend about 15-17 minutes of face-time with their patients. Unfortunately, much like us, PCPs are doing the best they can in the healthcare system they’ve been given. In order to reduce wait times for patients they’re having to see more patients per day, while also dealing with heavy admin burden.
PCPs are supposed to be the “quarterback” for the patient’s healthcare, yes? 15-17 minutes seems almost impossible to efficiently, effectively, and completely address all of someone’s healthcare problems and concerns. I’ll be honest, it’s not a position I envy. It’s like giving the quarterback 0.5 seconds to make something happen before getting sacked on their ass.
So if PCPs are Pat Mahomes, even though he’s really good, maybe us PTs could help our QB out? We could be their Travis Kelce, making a great run into the end zone for Pat to pass it off. Or their Creed Humphrey giving him a little more time to make something happen. (Yes, I’m ready for the Chiefs hate in the comments section).
So let’s say primary care PT became standard practice, that opens up a good chunk of time in a PCPs schedule. What could they accomplish with that extra time? It’s not necessarily up to us to decide but here’s what could be possible:
They could listen to their patients’ concerns and fully address them – reducing need and cost of follow up visits.
They could educate the patients on their chronic diseases and discuss comprehensive treatment plans. This would reduce hospitalizations and appointments due to the secondary conditions caused by disease.
They could review medications to decrease over-prescription and polypharmacy – reducing overall drug costs.
They could talk about preventive health and complete screenings for early detection of disease – reducing overall healthcare utilization by creating a preventive versus reactive system. .
The added time primary care PT would give general practitioners could reduce healthcare cost AND lead to happier, healthier patients. To be honest, I’m not sure how one would go about trying to calculate the total healthcare costs that could be saved both directly and indirectly as a result of primary care PT, but I’d guess it’s somewhere around a shit ton.
Taking it a Step a Further
But what if we took primary care PT a step further? What if we started treating it like all other primary care? We see a PCP once a year, ophthalmologist once a year, dentist two times a year so why not a PT once a year? What would the potential benefits of that be? I’ll tell you:
Maybe we identify the balance deficits in the 85 year-old lady BEFORE she falls and breaks her hip.
Maybe we nip that middle-aged man’s nagging low back pain in the butt BEFORE it becomes debilitating leading to costly surgery and/or opioid prescription.
Maybe we bulletproof the electrician’s shoulders BEFORE they tear their rotator cuff and can’t work.
I could go on and on because the possibilities really are endless here. Not to mention a yearly PT visit would be a great time to educate someone on general exercise recommendations given their medical history, limitations, or preferences. These conversations could be what sets someone on a healthier path and decreases their likelihood of developing chronic conditions or disabilities that cost the healthcare system millions every year. We take primary care PT to this level and I’d say we have a whole other shit load of savings on our hands.
An Open Letter to Insurance Companies
Dear insurance companies, this is where I speak to you directly.
Hopefully you have time to look up from the latest denial for a treatment or procedure you know nothing about and/or can’t pronounce. If you’ve read this far hopefully you see how this could benefit you as well. In case you still don’t get it though I’ll give you an example:
Let’s use 82 year-old Betty as a hypothetical patient and walk through a couple of scenarios.
Scenario #1: Betty sees a PT for her annual primary care appointment. Based on her age, the fact she lives alone and some of her subjective reports the PT performs a balance test. The balance test shows Betty is at an increased risk for falls, even though she hasn’t had any yet. The PT discusses this with Betty and she agrees to come back to PT to work on her balance and strength.
The PT sees Betty for 10 sessions, she gets stronger, more balanced, more confident, makes some home modifications from her PT’s suggestions, and gets a much better score on the balance test at discharge. Betty goes off to continue to live independently without falls and lots of visits from her grandchildren. Let’s say Betty had 10 sessions of PT at about $300 per session. Total cost of care for scenario #1: $3,000.
Scenario #2: Betty has regular PCP appointments but doesn’t mention her balance since she’s never fallen, just a few little stumbles here and there. Plus there’s so much to go over in so little time with the PCP, balance concerns move to the bottom of the list.
Unfortunately, one day, Betty does actually fall and can’t get up (thank god Betty has Life Alert). Betty is taken to the hospital and x-rays reveal she has a femur fracture. Betty gets an ORIF the next day. She stays in the hospital for a couple more days and is then transferred to a SNF where she stays for a month. Finally she goes home and gets home-health services for another month and help from family till she’s back on her feet again. Let’s take a look at cost breakdown for this scenario:
- Ambulance: $1,300
- Hospital Stay: 4 days + Surgery costs: $20,000
- SNF stay: $8000
- Home Health Services: $6000
Total cost of care for scenario 2: $35,300
Now, my numbers are based on my best guesses and limited research as far as what these things cost. (Price transparency still isn’t easy folks). More than likely some of my numbers actually even down-play the cost in scenario 2. Regardless, it’s plain to see that financially, scenario 1 makes a whole lot more sense.
So insurance companies, after taking a look at Betty here it’s clear you get something out of primary care PT as well. Here’s the thing though – if we PTs are going to be saving you and the rest of the healthcare system all this money being used as primary care physicians WE NEED TO BE PAID LIKE IT.
All this primary care biz will make PTs busier than ever and will only drive up our demand. There needs to be enough PTs to fill that demand, but we have less people going into this profession and plenty of people leaving it due to high debt and low pay stemming from low reimbursement rates.
This will only work for us, patients, and YOU if there’s enough PTs. You’re losing us quick though, and you’re not doing much better with PCPs either. PCP shortage is already a problem partially due to your admin burden. So unless you start to make some changes, good luck seeing the rest come to fruition.
The day of reckoning for the US healthcare system and insurance companies is coming. It’s already started. New models of care are being trialed and put into action as we speak. Many of these models reduce or closely eliminate the need for you altogether. We may not crack the code tomorrow, in the next 5 years, or even 10 years. I might be a decrepit old lady in long term care heckling some poor new grad PT by the time we figure it out.
No matter what happens, us PTs, PCPs, and all other healthcare workers … we’ll be fine. We’re adaptable by nature. It’s part of the job. Who’s to say we won’t adapt so well that we find a way to make you obsolete? Just maybe. When the day finally comes what side do you wanna be on? Do you want to be part of the problem or the solution? Do you want to be first or last? Healthcare is just like any other business – if you’re not first, you’re last. And if you’re last, who’s to say you’ll survive?
Making Primary Care PT a Reality
Okay PTs, back to regularly scheduled programming because if there’s anything we’ve learned it’s that we can’t rely on insurance companies to make things happen. All this primary care talk is great but how do we begin making it reality? The good news is that almost every state has direct access – some more limited than others. If you’re not sure what your state’s level of direct access is, here is a link with the details for all provisional or unlimited direct access guidelines. I highly recommend looking at this as the rules vary WIDELY from state to state.
Now it’s great to have direct access, but what good is it if no one uses it? What if the reason no one uses it is because they didn’t know they could? I would guess well over half of our patients don’t even know what direct access means, much less if their state has it. The average person doesn’t know this stuff.
The first step in advocating for increased access and promoting primary care PT is honestly pretty easy. When the opportunity presents itself we need to let patients know what direct access is, that they have it, and that they should use it. Your patient doesn’t want to have to schedule or pay for another PCP visit the next time a musculoskeletal issue pops up? Great, tell them to just come see you.
We can’t reap the benefits, see the improvements, or advocate for the advancement of primary care PT if we don’t even use it in the first place. The only way that will happen is if we spread the word ourselves. So the next time the opportunity presents itself to let your patient know about direct access in your state – use it.
Once we start bringing more awareness to direct access and patients begin regularly utilizing it we can start asking ourselves more exciting questions: What does a preventive model of primary care PT look like? How do we implement it? But that, my friends . . . is a whole other blog post.
Come back in a couple weeks for primary care PT part 2! Hit “subscribe” below to get added to the email list so you know when it’s out! In the meantime check out last week’s post if you haven’t already and follow on Instagram @the_pt_page!
Sources/Related articles:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054840/
https://pubmed.ncbi.nlm.nih.gov/30962224/
https://academic.oup.com/ptj/article/101/1/pzaa201/5999910
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-019-2553-9
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