Practice What you Preach! Why I left a traditional PT job to start a cash-based practice

Insurance companies, government agencies, and corporate leaders all preach about prevention, quality care, and patient-first practices.  However, they do not provide the framework to support any of these values. They do not listen to healthcare professionals, those on the front lines, regarding what will be most beneficial for our patients and the most efficient use of resources. Instead, we are inundated by a constant barrage of paperwork, policies, and procedures that keep us from caring for patients in the most optimal way.  This is a disservice to patients and healthcare providers, because you better believe that the vast majority of physical therapists (I cannot speak to other healthcare professions) went into this field eager to help people and make a difference.  Instead, the unrealistic and irrelevant burden of red tape is contributing to poor outcomes, clinician burnout, financial strain, and lower quality of care.  
 
I don’t have a quick fix for the system, but I do know that the values need to match the machinery of our healthcare system. I know that we need to offer an environment that promotes patient-first practice, preventative medicine, wellness-based services, and more discretionary use of invasive procedures.  We need to streamline our healthcare system from the bottom up, starting with medical education. We need to eliminate the middle-men on the clinical and corporate levels in order to decrease the absurd amount of money wasted on administrative costs instead of actual healthcare services. We also need to utilize our resources more efficiently instead of wasting money and time with imaging, testing, and surgeries that are often unnecessary. Overall, there are just too many barriers preventing effective communication, too much legislation with ulterior motives, and too many hoops to jump thru for insurance.
 
Let’s focus in on some contextual examples relevant to physical therapy…
 
Documentation
 
I value documentation, but the documentation I do is not taken into consideration for the decisions that matter. Insurance companies never lay eyes on the qualitative, descriptive assessments and treatment plans based on direct interactions with patients for multiple hours per week. Instead they provide forms, forms filled with boxes requesting quantitative information that we consistently learn in school is the most inaccurate way to assess patient status and progress. Furthermore, they ask for it so frequently we do not actually expect to see change that is considered clinically important per the research. So, not only is this extra paperwork on top of the growing burden for daily visits, re-evaluations, and initial evaluations, but it is not constructive. Metrics that are not supported in the literature are being glanced over by paper pushers with no patient contact and used to determine how many visits these patients get, as well as what types of services are “necessary” during those visits.
 
Why not let the clinicians who are experts in optimizing the neuromusculoskeletal system for return to functional status make the call on what a patient needs? Do they not trust us? Believe me, we as clinicians do not want to keep even our favorite patients around longer than needed. We start planning for discharge on day one, because that is a success.  My job is bittersweet, because when I no longer get to work with an individual it means that they are better. It means that I did my job and they have returned to doing what they love. So we are not trying to make a buck by keeping a patient an extra month, trust me the reimbursement rates from insurance companies aren’t that lucrative anyway!
 
Let’s keep riding the paperwork train to the next stop…
 
Paperwork and red tape are akin to shackles on healthcare providers; they serve as a barrier to building rapport with patients, utilizing asterisk signs, and implementing best clinical practice during sessions when you are frantically typing on your computer. My time would be better spent performing literature reviews, applying evidence to patient cases, or completing continuing education rather than entering ambiguous metrics into my computer.  Physical therapy is an art, not a formula. Black and white diagnosis, treatment, and outcomes are the minority in our field. We learn in school that everything is gray, with the running joke that every answer to our questions started with, “it depends.” We learn the clinical prediction rules, the diagnostic clusters, the special tests and commit them to memory. Then we spend the later years in classroom and clinic realizing that they very rarely present this clearly. We learn how to interpret the gray and navigate the muddy waters while still applying best practice to encourage timely and effective outcomes.  We learn how to balance evidence and science with the reality that impairments do not happen in a vacuum but are rather shaped by our experiences, psychosocial factors, and cumulative insult to other tissues in the body. No herniated disc is the same, every case of patellofemoral pain is not created equally; there is no guarantee that someone will respond to the gold standard of care. We are taught NOT to be mindless robots that follow rules and clusters without original thought or critical thinking.  So, of course I cringe when I see forms that ask for metrics that are almost impossible to apply to some chronic cases. These forms distill intricate patient cases down to numbers in boxes, numbers that don’t matter.
 
Real patient example: 
I had a post-operative patient not cleared for any weight bearing activity after surgical fixation of femur fracture. After 6 weeks of therapy all mat-level strength, range of motion, and pain measures were “normal,” which I kindly indicated in their little boxes. But I explained very thoroughly in the tiny, tiny box designated for free response that he had made excellent progress within physician-directed precautions but could not walk, climb stairs, rise from a chair, or anything else a functional 27 year old should more than be able to do. He was cleared for progressive weight bearing within next week per physician, so I recommended continued physical therapy 2x/week for 1 month to progress weight bearing activity.”
Returned as follows,  “DENIED---discharge patient from physical therapy as further treatment is not deemed necessary due to objective measurements reported.”
 
Excuse me, WHAT?! NOT NECESSARY?  A 27 year old who cannot stand, walk, squat, climb stairs, etc. does not need more physical therapy once he is allowed to put weight on his newly repaired leg?!  It’s 8 pm later that week. My patient has missed a session and is unable to schedule more.  I’ve called the insurance company 2-3 times per day including on my own time from home. I finally get a call back at 7:30 one evening while I’m at the gym inquiring about the issue. After 15 minutes of discussion, they finally pull up the paperwork (because my verbal explanation as a doctor of physical therapy wasn’t enough) and find where I wrote my request for continued care. Her response, “Oh, I didn’t see that. We will clear him for 4 more visits.”  All she did was look at the boxes and see that his strength was 4+/5, which is arbitrary anyway, range of motion was “within normal limits” and he had minimal pain. She did not read what mattered. And even when she did a week later, she only approved 4 visits.  This was my first big experience as a new grad of the lunacy of our system.
 
Now, I realize there has to be some formula some objective way for insurance companies to determine how many visits to authorize, but let the clinicians have a real voice. Let the assessments we painstakingly write matter. They are the most important part of our documentation, but many clinicians I know boil it down to one sentence now “patient tolerated treatment without compliant, continue per plan of care.” They do this because they are fatigued and know it will not be considered. Now, I firmly believe in writing descriptive, informative assessments for my own reference and that of other clinicians who may work with my patients. But why not let that information paint the context of the objective measures we provide to insurance companies. Why not value the voice of the experts over numbers in a box. It’s like fitting a square peg in a round hole when they ask us to fill these forms out.  And even worse is that many (not all) MDs do not often read our notes either. We are kept on this leash that keeps getting longer but won’t be taken off, which puts us in no-man’s land. With MDs writing ambiguous scripts even for post-operative patients but then still requiring us to send in documentation that is not signed efficiently enough to prevent lapses in patient care. There is poor communication. We need to be respected as a doctoring profession and be able to speak freely with MDs without censoring our dialogue. I should be able to say “ I suspect cervical nerve impingement as primary driver of Pt X’s shoulder pain vs deltoid strain.  He has not responded to conservative care and may benefit from further imaging and/or cortisone injection to improve tolerance for PT.”  I should not fear upsetting MDs by simply suggesting a diagnosis or requesting imaging.  We spend the most time with patients and see their symptoms in the context of functional testing and active treatment.  
 
The consequence is that our healthcare system bleeds resources without results. We learn about interdisciplinary care, prevention, wellness, evidence-based practice, critical thinking, the value of the subjective interview and listening to patients.  But yet, we are not given the time to build rapport with patients , we are double and triple booked because reimbursement rates continue to go down. So, the visits patients are getting are not as impactful as they could be. Patients are not allotted wellness services and are often cut off before they are ready for discharge.   In a typical hour I  was juggling 2 and very occasionally 3 patients, filling out insurance forms, documenting on my computer, and cleaning equipment as I went. Functional MRI studies show we are inherently bad at multitasking, no matter how relatively “good” you may be at it.  So how can I be expected to think critically about manual interventions on a patient, apply test-retest criteria, and at the same time cue and progress corrective exercise for another other patient across the gym?  I did my best in a traditional clinical setting, and I think I did better than many based on patient feedback, but I could not provide gold standard best practice care to both patients during a given hour. It was safe, excellent, beneficial care; it was not negligent in any way. But I firmly believed I would be happier and could help patients get well faster if single booked.  Seeing one patient at a time should be the norm, not a luxury.  

SO, I LEFT.

After only 3 years I left my steady job so that I could put more energy into practicing how I WANTED and work FOR PATIENTS not insurance companies or corporate practices that have lost sight of what is most important.  I am truly passionate about what physical therapy can do in terms recovery, prevention, function, and overall wellness, and now I have the freedom to share that vision with others!
 
Working cash-based allows me to do the following:

• see patients 1:1 for a full hour, or more if needed. I no longer have to see 2-3 patients per hour just to make ends meet because of low reimbursement rates
  
• determine appropriate frequency and maintain continuity of care
  
• transition patients seamlessly to wellness services as appropriate
• apply evidence-based practice in terms of technique selection, exercise prescription, and dosing. My treatment plan is driven by what will be most beneficial to patient…period.
  
• critically think during session and utilize test-retest principles
  
• perform un-limited patient education to truly improve self-efficacy and empowerment for long-term success.
  
• take extra time with a patient if an hour is not enough
  
• spend energy reflecting and thinking on a case, and be available to answer questions in between visits.
  
• document exactly what I feel is relevant. I have the time to write quality assessments and enjoy documentation again because it is manageable.
  
• design high quality home exercise programs and make health behavior change a priority
  
• see a low enough total number of patients that I don’t get burnt out!

 
And I can tell you, it is working!