Health Care is changing. Cost of services are going up as the tests and treatments are becoming more elaborate, technical, and expensive. Insurance companies are requiring additional justification for services rendered and reimbursement denials are more common. Most people have large deductibles and co-pays for single visits (up to 75$ or more). However, one thing that has become common knowledge is that if people are not physically active, they will have a significant increased risk of heart attack, stroke, diabetes, or bone/joint related diseases. The general population understands this but, people are still getting lost in the system (not getting better, getting frustrated, and returning in 6 months for the same problem). The answer to this problem is bridging the gap between health care, wellness, and fitness.
Due to the rise in health care costs, there is an incentive and desire for longevity around the treatments that patients are seeking. Some people are doing personal training, massage therapy, tai chi, or other forms of cash based programs. Some are going out on their own in the gym, hiking trail, or pool. Many are successful with an independent fitness and prevention program, but some people really do need guidance, technical assessment, manual treatment, and correspondence with their health care provider. When a client is referred for rehabilitation (due to a functional limitation), they follow with a series of visits to progressively improve their ailment. Once that patient has become independent with the management of their ailment or they have returned to being able to care for themselves, the medical necessity ends.
After 1-2 months of Physical Therapy, most people still have large deficits due to long standing pre-existing weakness, general de-conditioning, or lack of time / motivation to continue their program. Insurance does not pay for lack of follow through. Lack of improvement beyond 2-3 visits will typically necessitate denial of services the insurance company. Most patients form a bond with their Physical Therapist and want to continue therapy. WHY NOT? By offering a cash based program at the same facility at the price that is generally less than the cost of one co-pay (10-20$/class), patients can continue doing wellness classes. In addition it is more personal and motivational working with the same Physical Therapist and facility that got you through the initial injury recovery process (such as a total knee replacement).
We can take it a step further by bridging the gap between cashed based wellness classes and performance enhancement. That same client who has recovered from his total knee replacement and has attended a general conditioning class for seniors (cash pay) for 2 months thinks he is ready to resume golf. Medicare does not not identify golf as an essential functional activity and will deny any services that attempt to use it as justification for continuing treatment. Why not get an assessment, video analysis of the golf swing, and online home exercise program by the same Physical Therapist that treated you 2 weeks after your knee replacement? This program is much more expensive than the wellness classes but that one visit will get you on track to enhancing your golf game, injury free. This same model can be used for the triathlete recovering from Achilles tendonitis or the office employee with neck pain who wants to lose 20 lb.
Bridging the Gap between all levels of physical health care will be the only option in the next couple of years. Currently, patients are being lost in the system due to lack of follow through, compliance of rehabilitation, and insurance coverage limitations. Patients will be required to care for themselves regardless of their ability to remember exercises, motivation levels, or recovery time. The Physical Therapist can act as a resource and coach through the entire process. This movement towards a “Wellness Model” is being introduced an utilized in many clinics. Ideally “Wellness Facilities” will become commonplace in Physical Therapy and Fitness practice for better outcomes with all levels of wellness. I hope that eventually insurance companies will see the lasting benefits of a structured prevention program and include “Wellness Club” memberships in their health care plans.