10 things I’ve learned in 10 years as a PT (pt 2)

This blog is part 2 of the 10 things I’ve learned in 10 years as a PT. You can check out part 1 with the first 5 things here.

Here we go with numbers 6-10!

6) Insurance companies don’t care about our patients

Unfortunately this is something I learned very early in my career. I cannot tell you how many times in my 5 years working in insurance based practices that I saw patients be cut off by their insurance company before they were ready to be discharged from PT. This was sometimes because they were only allotted a certain number of visits per year (which was just an arbitrary number determined by the insurance company), or because someone reviewed their case and deemed PT “not medically necessary”.

I once evaluated a patient who was on partial weight bearing precautions and had to be in a walking shoe due to a foot injury. He shared with me at the evaluation that he enjoyed running and that it was a goal of his to get back to it. I wrote goals for him to be able to walk independently, negotiate stairs, work without limitations, etc. Then I wrote one long term goal about return to running. When we submitted for authorization to his insurance company, they only allowed him 6 total visits because they said running was not medically necessary. So they ignored all of my other measurements, goals, and recommendations and picked just one goal I wrote to justify denying services to their customer - who was currently unable to walk independently or without a boot. 6 visits was nowhere near enough to get this man the care he needed. Is running medically necessary? Maybe not, but it may also have a very positive influence to this man’s health, both mentally and physically (ultimately driving down his overall cost to the insurance company).

I also realized early on that coverage of the number of visits was not the only thing the insurance company determined, but also what they would reimburse for. On one of my first days working as a PT, I was getting ready to set up a patient on estim at the end of their session. My manager quickly pulled me out of the room to tell me that I needed to do ultrasound instead of estim, because the patients insurance wouldn’t cover estim. I knew ultrasound wasn’t the treatment she would benefit from most (or likely at all), but I was a new employee and felt like I had to agree and move on.

I also worked for an employer that scheduled patients based on their insurance. If they had a federally funded plan like Medicare or Medicaid they had to be 1:1, because that was how we maximized payment (otherwise for Medicare we would have to charge as a “group” and would only be paid one unit). However, some private plans paid a flat rate regardless of how long the patient was seen or how many units were billed, so we were encouraged to group those patients with others and to get them out the door as quick as possible. The employer of course would always say “be ethical do what’s best for the patient”, but these metrics were all tracked and our raises were dependent on performance so - I’m sure you can see the problem here.

The 2 major consequences here are:

• Patients don’t get the care they need. If they have higher level goals outside of basic self care needs, insurance deems their care “not medically necessary”. Oftentimes their care is being determined based off what their insurance will reimburse the provider for. Basically the insurance company is a middle man who is making decisions solely based on cost, and not what is best for the patient.

• PT’s get burnt out and leave the field. There are 2 major movements happening in PT right now: one is that PT’s are going to a cash model where patient’s pay them directly (this is what we do at AKPT), or really good PT’s are leaving the field completely. I am in a Facebook group that has almost 50,000 members that are PT’s, Occupational Therapists, and Speech Therapists, all discussing non-clinical roles to get into. I have PT colleagues who have left PT for jobs in tech, construction management, sales, and some in more traditional non-clinical roles like clinical reviewers. Although I am happy in some ways to see folks expanding outside the traditional PT world, it is sad when they leave completely due to burn out.

7) Most of the time you don’t need an x-ray or MRI before PT

I have so many folks who reach out and ask me if they need an x-ray or MRI before starting physical therapy. The truth is, medical imaging is simply a still photo of your body in the position it is in at that time. There is a lot of evidence showing that many of the things we see on imaging that might be noted as “abnormal” are actually normal changes with age, and we don’t have evidence to prove that what we see on an image is what is causing pain.

Pain is complex and can have many contributing factors. As PT’s, we are trained to screen patients for any red or yellow flags that may indicate they need to get imaging or further testing with their physician. Also, imaging is expensive! Seeing a PT first for things like back pain, joint pain, neck pain, pelvic floor dysfunction, and non-traumatic injuries can save you both time and money.

8) Listening is our most important skill

I can remember having professors in physical therapy school tell us that if you learn to listen well, your patients will tell you what is wrong with them. I have always kept this in mind, and I’m thankful to have plenty of time in my practice now to hear my patient’s full story. As PT’s, sometimes we are the first provider who is able to take the time to truly listen to our patients.

When I started training in visceral manipulation through the Barral Institute, they teach clinicians how to listen with their hands. This has changed my practice so much. I’ve truly learned to trust what I am feeling with my hands.

9) Research and clinical experience are equally important

I am a big believer in evidence based practice, using research to drive our clinical practice. However, I truly believe clinical experience is equally important. Many of the interventions we use in PT are difficult to research, or are lacking high quality studies. However, we see over and over again that these treatments help our patients in the clinic.

I am always up front with patients about treatments that we have good research on, and ones that we don’t have great research on. I also share with them my experience. Patients are always involved in their care and what interventions we choose, and we can always make adjustments throughout the plan of care!

10) “It depends!”

This is a favorite saying for a lot of PT’s! The internet is full of advice, and oftentimes they are blanket statements that simply don’t apply to everyone. There are so many factors that go into healing, reducing pain, increasing strength, and working towards your individual goals.

Although in some cases advice online is provided by true experts and can be really helpful, there are also times where someone takes advice and it simply doesn’t work for them. If this is the case for you when it comes to advice from a PT, please don’t assume that PT won’t work for you! An individualized assessment can help determine what specific treatment may be best for you.

I’ve had a lot of fun on Instagram and through the blog sharing some of these things I’ve learned in the last 10 years! If you have questions, please feel free to reach out to me directly at alexis@absolutekineticspt.com.