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Toni Talks about PT Today

Physical Therapy Rationing

Published February 3, 2010 12:01 PM by Toni Patt
In the most recent electronic issue of PT in Motion, Jim Romeo talks about the future of rationing health care.  Mr. Romeo takes a more global view of the possibility.  He takes the position that any rationing will happen with the most expensive procedures and treatments.  This will be beneficial to PT because as one of the less expensive options, it will be utilized more often.  That is reasonable as long as you assume PT will remain readily available and cost effective. 

That view raises some interesting questions.  Will there be enough PTs to provide the necessary services?  Will there be enough options for consumers to have ready access to PT services?  What effect will the continuing cuts in reimbursement have on the practice of PT?  Do we really want to let others make decisions that have global effects on our profession?

The baby boomers are beginning to retire.  As more of them enter that age group the demand for PT will increase.   Those 65 and over are the ones who utilize our services the most in the most settings.  If nothing else changes we'll need more therapists to meet the demands of that cohort if they continue to require therapy at the same level.  The cost of getting a DPT will only go up and there is already talk about the price being prohibitive to prospective students. 

The reimbursement for therapy has been declining for years.  If the actual dollar amount isn't cut, the criteria for services is increased.  That trend has resulted in cuts in budgets, services and staffing of PT departments.  Fewer people are being asked to do more while completing more paperwork without an increase in pay.  That presents a dilemma. To make Medicare profitable a huge volume of patients must be seen. That volume will only increase as reimbursement decreases.  A higher volume would imply more therapists but that doesn't always happen.   That may result in a form of rationing at the provider level based on payment sources, severity of need and waiting lists.  My question is who will do the triage for PT services?

One of the goals of the APTA this year is to increase brand recognition of physical therapy.  This is part of the plan to implement Vision 2020. The potential benefits are great.  But then what happens?  Who is going to pay for the services all those new patients will need?  If the demand for PT increases the amount paid for services will increase.  At some point the increased cost will send up a big red flag and adjustments will be made.  Decreased reimbursement and increased patient cost will effectively ration our services.  Is PT going to become the next wonder drug that everyone sees on TV and wants when they see a doctor? 

OK, APTA and those pushing direct access, what is the plan if that happens?  Someone will have to pick up the slack for those patients.  One option is longer hospital stays.  A patient can't be sent home unless there is a safe DC plan.  Safe DC plans may well mean longer stays for PT to increase independence.  Hospitals will take a financial hit if that happens.   Decreasing length of stay is one of the few ways they have of cutting costs. 

There isn't an easy answer.  I don't think it's as simple as Mr. Romeo would like it to be.  Cutting down on expensive procedures may save some money.  But those patients will still require care.  Currently we lack both the staffing and infrastructure for a surge in caseload.  I hope someone is figuring that cost into the equation.

Romeo, J.  Rationing: What is the future of health care rationing? PT in Motion (electronic version)2010; 2: 26-31

posted by Toni Patt


I believe rationing in the USA is already occurring care of the Milliman guidelines. If your insurance company doesn't feel a procedure or practice is providing functional benefit or can be provided in a different setting, they refuse to pay. That is rationing.

Having worked many years in home-care, I can tell you that patients are being sent home quicker and sicker than before for this very reason. They are also being sent to outpatient practices perhaps more quickly than would be beneficial.

The APTA responds with a Madison Avenue approach. Marketing the brand. I hope that they have a lot of evidence showing how PT works and can state it in consumer friendly ways. Do we really want to be in the same category as Suzanne Somers Thigh Master? Everyone knows about it but nobody takes it seriously.

Dean Metz February 8, 2010 1:12 PM


As always, you raise a lot of good points.  Unfortunately, if anyone had answers - or the ability to implement answers - we probably wouldn't be in this position to begin with.

One comment stood out to me:  "A patient can't be sent home unless there is a safe DC plan."  I think you might be giving "them" (those who make and implement these decisions on our behalf) too much credit.  Who would have ever thought we would be discussing health care rationing in the US?  Is it naive of us to assume "safe DC plans" will still be a mandatory criteria for discharge if these changes in our medical system play out?

Janey Goude February 5, 2010 1:46 AM

Hey, kid! Wow! Doing a bit of research and look what I found! Happy to see you are well and thriving! BTW, I believe you have at least 25 years experience in the field, less time spent in pursuit of alternate endeavors. SLU was a million miles ago. Good luck with school, though as I recall, you won't require 'luck'. Drop a line if you have the time or inclination.%0d%0a                                     All Good Things,%0d%0a                                                            Ty T.

Ty February 5, 2010 12:38 AM

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