It is time for me to dig out from under the frustrating quagmire of paperwork imposed on me by my insurance contracts so I can reclaim my sanity and love of my work. I am terminating all of my in-network contracts, firing my billing service, and focusing my clinic time and energy entirely on patient care. Removing my practice from the control and limitations of healthcare insurance companies allows me to continue to offer extended one-on-one quality physical therapy sessions to my patients who are more to me than their injured parts.
I opened Harmony Physical Therapy in 1994 offering extended appointments for complicated patients. My patients were survivors of auto accidents who were thrown through the windshield in head on collisions or tossed around in their car as it rolled down a mountainside; they were victims of bike crashes, rock climbing falls and a variety of other serious accidents. These patients were often dealing with brain trauma that rendered them moody, forgetful, and foggy. I laid my hands on and worked stuck damaged layers of tissue apart, coaxed closed joints to open naturally, and transformed strained postural patterns into better balance – and I listened. I listened as my patients shared stories of travels, relationship struggles, traumas, job stress, personal victories, and grief. Emotional support became equally as valuable as physical support, and my extended appointments allowed time to provide it. This became my niche.
In the beginning, my time was fairly compensated by insurance companies. My husband was also self-employed so we had the flexibility to raise our family without the use of daycare services. We weren’t wealthy, but we got by and life had balance.
In 2003, after massive lobbying efforts by auto insurance companies in Colorado, the no-fault coverage for injuries sustained in auto accidents was abolished. Payments for medical bills related to auto accidents are delayed, sometimes several years, until the determination of who was at fault is sorted out in court. Injured parties, wary of navigating the legal system, often chose not to seek treatment and stuck it out with their pain. My niche was hit hard.
In a move to boost my patient volume I decided to join the managed care system and accepted provider contracts with major insurance companies in my area. As a solo practitioner, I had no negotiating power on these contracts; my choice was to either accept the low ball offers or to be left out of a stream of potential patients shopping for care within their benefit plans. The payments were per diem and priced to cover less than 30 minutes of direct-contact physical therapist treatment. I compromised by offering 45 minute appointments, but stubbornly continued to treat the complicated patients for an hour or more. This was not a wise business strategy, but it allowed me to maintain a pace I needed to function optimally with my patients. By 2012, I was working twice as hard as I did in the 90’s and barely earning the same annual income.
The paperwork demands by insurance companies has steadily escalated every year. The coding for Medicare claims is increasingly complicated. Time consuming data collection, patient surveys, pre-authorizations, and electronic medical record keeping are required to avoid payment rate penalties and flat out denials. I adapted by using an electronic health record service for an ongoing monthly fee. Electronic billing that streamlined from my records became necessary to save time on collections and chasing down lost claims; this service cost me a percentage my collections. Business and cost of living expenses climb higher and insurance reimbursement rates remain flat or diminished. The games insurance companies play to delay or deny payments have become unbearably frustrating. Despite keeping my overhead as low as possible and working more hours, my business model has become nonviable within the system.
Ironically, even though some of my senior patients are happy to pay out-of-pocket to see me, it is not legal for me to accept direct payment from Medicare recipients for physical therapy services; how strange, given the financial strain already on the system, that this law results in both higher cost to tax payers and restriction of the rights of seniors. This law can change only through an act of congress. Thankfully, my skill set can be classified as wellness and fitness care — services outside the realm of Medicare — my seniors who see me because they want to maintain their mobility can still be served at Harmony Physical Therapy. Those with rehabilitation needs, as in post-surgery, will be referred to one of my capable colleagues in the community.
In response to this news some patients say to me, “My deductible is so high I pay out of pocket anyway” or “I applaud you, your services are worth it” or, interestingly, “It seems simpler for everyone”. Others are gravely disappointed as their finances prevent them from paying out of pocket and they will have to seek care elsewhere.
My frustrations, within the complicated mess that is our healthcare system, are common among medical practitioners. The time demanded for paperwork is disproportionately large compared to the time allowed for meaningful interpersonal interaction. The insurance companies control the money and hold the power in the system. I am frustrated with both our government run system and the private health insurance industry so the solution is not clear. I feel compelled to point out, though, that as a consumer I pay more each year for my own health insurance while simultaneously receiving less as a provider within the system, and the CEO of United Healthcare is taking home upwards of $66 million annual income.