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The Therapeutic Dilemma

Sept. 24, 2013
To use physical therapy for a workplace injury or not, that is the question. At least that one largely has been settled in the last few years with many people opting for therapeutic treatment.

Physical therapy is about movement and how to make that happen. It's a good thing for injured people and measurably speeds healing and reduces the cost of care. 

 A recent study put a price tag on this: Adding therapy to musculoskeletal-injury treatment can save the insurance carrier over $2,000 per claim with quicker release and reduced disability.

The list of things improved by exercise is twice as long as your arm. Movement is good; it keeps the blood going round. Movement is good even if you are injured, old, obese, skeletal-thin or have almost any disease or injury you can name.  

Now that we have established that therapy is a good thing, where can you get it? That question is not as easy to answer. 

There are two main schools of thought: You can use the therapist who works with your doctor, or you can use a therapist who has nothing to do with the treating doctor.

Both carriers and providers are concerned about the cost of care. We know that good outcomes, achieved with the quickest and least expensive path, will bring long-term success to the companies we serve, their employees, patients and ourselves. Insurance carriers entirely are in agreement on these goals, but how to get there?

If you represent an insurance company and believe providers work by formulas, then you put procedures in place to eliminate any possible self-dealing. Keeping the provider and the therapist far apart might be one of those procedures. In your mind, one of the biggest challenges to closing a case quickly, economically and successfully is self-referral and endless therapy.   

Partners in Care

If you think having the doctor and therapist talk about the patient's progress is good, then you encourage the therapy being done in the same clinic as the medical provider.   

Separating the doctor and therapist can convert meaningful verbal communication into a review of indecipherable reports, often received after the patient has left. These reports are not written to communicate clinical information with the doctor. Instead, they are designed to get a therapist's bills paid. When an outside therapist calls me – and that happens once every 50 patients or so – it's to get a signature or ask for more therapy.

My relationship with the therapist who works with me in my clinic is different. If we just consider MRIs, over 50 percent of the ones I order are suggested first by my therapist. Those MRIs are about 85 percent positive for surgical pathology.

Am I simply late on the draw? No, it's because our therapist spends more time with the patients and has a different relationship with them. She is perceived by most patients as being "on their side," and they talk more openly with the therapist. 

By doing an MRI sooner, we save weeks of therapy before the operation and save thousands of dollars on the case.

Our therapist also doesn't like to waste her time. If someone has recovered, she walks into my office and asks me to see him after therapy and release him. She does this even if more therapy visits already have been authorized. 

What's going on here? Our therapist and I both are judged by the same ruler – getting the patient better with the most speed and cost effectiveness. She doesn't have a practice to support, nor do I. If we do a good job together and the patient gets better, the rest will follow. 

By the Numbers

Do the numbers support this? We manage to get 81 percent of new cases closed within 30 days. In the 17 percent of new injuries that need therapy, the average length of therapy was 5.5 visits if done by my therapist and 9.5 if done by an outside therapist. 

The partnership between a skilled occupational medical physician and the equally skilled therapist, both working with the same goal, is the most effective way to rapidly get injured people better. 

I tell the patient that we will treat him from the inside with medications, and from the outside with therapy and exercise. Even intuitively that sounds like a "can't-lose" strategy. 

Donald Bucklin, M.D., is a regional medical director for U.S. HealthWorks in Scottsdale, Ariz., and has been practicing clinical occupational medicine for more than 25 years.

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