A Broken System: Part 1
“HealthCare” isn’t really about either anymore. The current system is no longer about promoting health or taking care of patients. The saying “follow the money” seems to hold true here. The people making the money usually aren’t the providers and the patients aren’t getting value from their money in many cases. How is it that a system intended to help instead leaves people in need and providers drowning?
What went wrong? Well, I worked corporate PT for almost 12 years, managing a clinic in downtown Philly for about 3.5 years of the time I was there. Almost a decade ago now, our overhead cost to treat a patient for 1 hour was about $80-85. This cost included salaries of involved team members, rent/utilities, supplies, etc. Many of our insurance plans were reimbursing significantly below that— sometimes as little as $17.20 (I’m looking at you Medicare). The average reimbursement we received for 1 hour of treatment was $65. So, we started about $20 in the hole for every visit.
Now yes, there were co-pays— for some. Many of our patient’s couldn’t afford their co-pays ($30 was cheap even back then, but I often saw as high as $75-90/visit). There were also plenty of subsidized plans which had smaller or no co-pays— and were usually the lowest to reimburse. I had no choice but for myself and my staff to double most appointment slots to make ends meet and even show a small profit margin above necessary equipment replacement, upgrades etc. Trust me, I wasn’t raking in the dough. In fact, I barely got any raises as my clinic wasn’t “making money” and only 1 year did I get a small bonus- which I split with my staff. Without their hard work there would have been no bonus.
When the bonus became a 4 way split with my management tree, it meant my clinic (and my team) would get the smallest cut. What did the upper management do to earn a bonus? Management negotiated reimbursement contracts (which declined annually). Management negotiated my rent (which of course went up every year). Management set the policies and contracts for ordering equipment. Most of these decisions negatively impacted my clinic’s bottom line. Yet when I would find a way to “make” money, my team were the last to get a piece of the pie— and the smallest piece at that? Nope, I’m out. I was breaking my spirit working 60-70 hour weeks trying to provide top level patient care to too many patients, write notes to meet insurance requirements/standards, train staff, do reports, etc etc etc, but no recognition when against all odds my team found a path forward?
My next move was Military Medicine. Great! I can be an autonomous provider. I can use all aspects of my education and training. I will be seen as a physician extender and able to order imaging/labs and truly help my soldiers at the highest level. However, Military Medicine is still working under “insurance”— think Medicare on steroids (with extra government policies). I had no control over my schedule or template, when or how my soldiers were scheduled, if there was any continuity of care between visits, or if scheduling offered my soldiers and I enough time to actually do anything successful. I had a rolling caseload of 300-350 soldiers at once. Most with multiple issues. And often with about 30 minutes or less to see them, once a month if I was lucky. The PTA’s we had on staff were AMAZING (I can’t say that enough). But, even they were stretched thin, meaning maybe I could get my patient 30 minutes once a week, at best…
What does this all mean? The private insurance system doesn’t work- patients often can’t get (or can’t afford) what they need, and providers aren’t reimbursed in a way to allow for patient care to come first. Insurance companies are making money (even the non-profit ones— it’s called salaries for the executive officers). On the flip side, the socialized system is also not sustainable with a large population due to long wait times, lack of providers and lack of patient onus on their own progress or issues. And often increases taxes to everyone (decreasing take home pay for everything else in life).
Did you know the average cost of premiums for a family of 4 in 2023 was $23,968, compared to $12,680 in 2008? Family premium costs have doubled in the last 15 years, while I’m guessing most families incomes haven’t. These costs are before co-pays, deductibles, co-insurances, etc. While plans are now required to provided “minimum” coverage, this usually means specialty treatments (i.e. Physical Therapy, Speech, Counseling, Orthopedics, etc) are given lower visit allotments or more stringent authorization processes to cut costs on behalf of the insurance company. Remember that $75-90/visit I mentioned earlier? I have now heard of PT co-pays as high as $175-185/visit, and high-deductible based visits as high as $700/visit— but only after you paid your premiums for this plan. If the traditional PT “prescription” is 2-3x/wk for 6 wks, could YOU afford those co-pays or visit costs? Even if you could, would you then want to pay that much to be doubled, or provided generic exercise sheets? I know I wouldn’t…
My career path has shaped how I viewed what we do as Physical Therapists, A LOT. I realized education was my most powerful tool. I learned to lean into that and did the best I could. I learned to teach my patients how to develop strategies for self-care and how to get the most between visits. But again- hours upon hours of unpaid time to document notes and get all the extras done if I wanted to provide the absolute best care.
Our current health care system is a Disease Management system. We manage symptoms and diseases. We don’t CARE for people. There has to be a better way. A way to provide education based care which is valued by the patient and at a sustainable pace for the provider. By freeing myself from the constraints of insurance-based care I am able to do exactly that— EDUCATE and EMPOWER my patients to understand their body, movement, and pain; and to develop a sustainable path forward.
Curious to know more of my thoughts about getting away from Disease Management and forging a path back to patient-centered Health Care? Make sure to sign up for emails— Part 2 coming soon!
