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Sunday, March 8, 2015

Which Physical Therapy Practice Is The Best One To Go To?

The intention of this article is to help educate the patient on the different types of physical therapy practices and then how to decide which one is best for them

Choosing a physical therapist (PT) or physical therapy clinic is like choosing any primary healthcare provider.  Physical therapists are primary healthcare providers in most states now.  You also do not need a referral from a physician to attend physical therapy in most states.  Once you've decided on a PT, you'll most likely stick with this therapist for any subsequent injuries just like a primary care physician.  There are several types of PT practice models that operate in every state.  What I'd like to do is go through these practice models in order to help you decide on how to choose a PT if it ever comes to that for you. I'll then tell you the practice model that I really like and used in my PT practice.

There Are Three Types of Physical Therapy Practices

  1. The Altruistic or Original Physical Therapy Practice
  2. The High Volume Practice or Clinic
  3. The "I Don't Know You" Practice or Clinic (This is my own label)

The Altruistic Or Original Physical Therapy Practice - Physical therapy initially began on a volunteer basis.  In the short of it, physical therapy initially got it's roots during the big polio outbreak several decades ago.  Physical therapy was initially administered by nurses or nursing aides (at that time called restorative aides) in order to restore motion to affected limbs of those suffering from polio.  By performing range of motion activities, this relieved extremity pain and restored, to a certain level, the function of the affected limb and the function of the patient.  Over the years physical therapy extended beyond just treating polio patients.  It was found that earlier movement after surgery provided better recovery outcomes.  Clinical and scientific studies began in depth and found that physical therapy provided much more to patients than one could imagine.  Physical therapy evolved to what it is today - a multi-disciplinary medical practice.  Physical therapy absolutely has it's place in patient care.  

I want to be as politically correct as possible but I also really need to inform you of the benefits of a original practice model.  Original practice models focus much more on the patient vs. how many patients a practice can get in the door (high volume practice & I don't know you practice) as well as their profit margin.  Yes, physical therapy is a business and practices need to make money.  However, patients should not suffer because of a greedy clinic owner.  With an original practice model, you will be the focus of attention.  You will be thoroughly educated with your injury, your plan of care, and what you should be doing and shouldn't be doing at home.  In addition, the therapist will spend a significant more amount of time with you.  You will have a very customized treatment and plan of care vs. a generic treatment at other practices.  The time you spend at physical therapy will be with a PT and not a physical therapy tech or other ancillary staff.  Another benefit of the original practice is that the PT will usually be much more thorough in their documentation with regards of how you are doing and with regards to communication with your physician if a physician referred you to physical therapy.  The bottom line is, the quality of care will be much greater than at other practice models.  

As previously stated, physical therapy is a business.  Physical therapists get paid from insurances just as medical doctors get paid from insurances.  But some physical therapy practices are more concerned about their profit margin (high volume practice) vs. a balance of proper care and profit margin.  This is where the original physical therapy practice once again comes in with high marks.    Ethical care takes priority.  The original physical therapy practice has a very nice balance between making money and giving the best care possible to the patient.  If a patient is able to find more of an altruistic practice model, then that person will see and feel a tremendous difference in patient care and see the difference with ethical billing practices.  However, for the Original clinic owner, keeping open appointments on the schedule becomes problematic due to the patients wanting to get in to the practice.  It doesn't take long for the Original practice model to develop a very good reputation.  It's this need to see patients that many clinic owners will adopt other practice models.  But good patient management, good time management, and adding a like minded PT to the practice can offset the need to morph in to a less ethical practice. 

Something that is very noteworthy and of great importance with an altruistic or Original PT clinic is that more responsibility is put on the patient with regards to compliancy with their treatment and plan of care.  This is because of the customization and Education that a patient receives in a Original practice.  The  Original PT practice is one that spends more time with a patient one on one.  This one on one time is to be able to educate the patient about their condition.  This isn't just a story telling time.  This information is meant for the patient to use during their recovery and be responsible for their recovery. If a patient is going to receive this kind of care then this patient needs to reciprocate and be responsible for their home care instructions.  However, being responsible with home care should be the case no matter the type of practice a patient goes to.  A patient should always follow through with the educational instruction from the physical therapist.    With other practice types, the so very important education of the patient is left out.  The patient goes through their physical therapy process without knowing why they are doing what they are doing.  So without further explanation here is an itemized list of the pro's for seeking out an altruistic or Original practice model:
  • You will always see the same physical therapist
  • You are held responsible for following the instructions by the PT for proper recovery.  Non-compliancy with this can mean discharge from physical therapy whether you have recovered or not.  Non-compliancy is often referred to as "waste of resource" by a patients insurance company if the patient is using insurance vs. cash paying patients
  • Because you will always have the same therapist, problem solving of your injury is performed in a much more competent manner
  • Your plan of care will remain consistent
  • Progression of your care will occur at the right intervals and will be communicated in a timely manner to your referring physician
  • Of great importance, you will be fully informed of all aspects of your injury and pathology.  So education regarding your care and recovery will be covered thoroughly
  • This type of practice most often does not use ancillary staff such as PT techs, aides, or athletic trainers.  If ancillary staff are used, then they too will be educated fully on your plan of care.
  • Discharge will be performed at the appropriate time.  
  • The therapist does not see as many patients in a day as does a high volume clinic or an "I don't know you" clinic.  This results in better documentation and very ethical billing practices.  
  • On the downside, these clinics are harder to get into.  Once you do get on the schedule it is up to you to maintain your schedule, limit deviation of your schedule time, and absolutely do not miss your appointments.  A good altruistic clinic is hard to find and often even harder to get into.  The best care comes from these clinics!
The original type of practice is absolutely my preferred method of practice.  Persons who do attend the high volume clinics do receive care that improves function and healing but the quality of the care is often questionable and of poorer quality.  So, if you ever have to attend physical therapy ask the clinic how many patients a therapist will see in a day.  If the number of patients exceeds 12 - 14 in a day, then you're looking at more of a high volume clinic and ancillary staff are most likely used.  Also make sure you will be seeing the same therapist each visit.  Clinics that treat patients with varying PT's are typically hospital based outpatient clinics and high volume clinics.  

The High Volume Clinic - The title already does a good job of describing this type of practice.  A high volume clinic is one in which a patient is seen more or less for just a few minutes by the PT.  Once the PT has checked in with you, you are then handed over to a PT tech, exercise physiologist, or an athletic trainer.  A high volume clinic is one that mostly benefits the owner of the clinic vs. benefitting the patient.  The more patients seen then the more money the clinic owner can claim in billing.  Often high volume billing practices are unethical.  

Education of the patient in a high volume clinic with regards to their injury or plan of care is minimal.  Because the PT comes and goes so quickly in a high volume clinic, the education of the patient is significantly bungled or left out all together.  What I mean by this is, the patient goes through the motions of physical therapy but they have no idea why they are doing what they're doing.  Nor does the patient get a thorough explanation of their pathology that brought them to PT in the first place.  

Next, with a high volume clinic, therapeutic exercises or activities are prescribed and then it is up to the PT aide or tech to perform these activities with the patient.  Once again, the PT aide is going through the motions with the patient but doesn't know exactly why the patient is performing a specific routine.  A huge downfall with this is that the tech doesn't know what signs or symptoms to look for that might be contraindicated for the patient.  The next thing to mention is, with a high volume clinic, prescribed exercise routines become the mainstream for everyone.  

Quick Editorial - Most times "filler" exercises are added to a routine just to keep a patient busy and  to accumulate time in the clinic.  These filler exercises are often not even related to the patient's injury.  They are added in order to accumulate the time you've spent in the clinic so that the clinic can bill you for this time.  

The mainstream exercise routines are because the PT doesn't have the time to customize a proper therapy protocol for a specific patient.  I have seen this first hand in several clinics and it ruins my whole concept of what physical therapy is supposed to be.  I have seen someone with a shoulder injury performing the same exercises and therapeutic activities that a patient with a total knee replacement is performing.  This does the patient no good at all.  It is also a very unethical practice.  Why would someone with a shoulder injury be performing exercises for their hip or knee?  Again, the answer to this is that the PT is too busy to customize and then educate the patient on a proper therapy protocol.  So instead of taking the time, the PT will hand the PT tech an generalized exercise flow sheet and have the tech perform this generic routine with the patient.  In addition to this, as the patient heals, the protocol needs to be changed or progressed in order to match the rate of healing of the patient.  With a high volume practice, the progression of a therapy protocol is not maintained.  Again, this leaves the patient in a "healing" limbo.  Of significant importance with this healing limbo, the patient's insurance only allows so many visits to physical therapy.  So each time the patient goes in to physical therapy, they are paying for something that is useless and something that the patient has a very poor chance at recuperating.    

Next, what happens when the patient has met the ability to perform the initially assigned therapy protocol?  They are usually discharged and are discharged prematurely.  The strength and function that was supposed to be acquired in order to go back to their regular work and recreational activities was not acquired.  This leaves the patient very susceptible and prone to subsequent injuries and poor long term healing.

As in typical fashion in my articles, I'd like to give you a simple summary of a high volume clinic:
  • Minimal time is spent with the PT
  • Proper education of the patient and the ancillary staff are not met
  • A proper therapy protocol is often not met
  • Proper progression of the therapy protocol is not kept up to date
  • Unethical billing practices occur and this translates over to the patient paying for something they didn't receive
  • The patient does not receive the care that they are paying for
  • Discharge is often premature leaving the patient susceptible to unfinished healing or subsequent complication of the current healing
  • There is poor documentation of the patients status.  Proper documentation is what dictates how much a clinic is reimbursed.
  • Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time

The "I don't know you" clinic - This is a clinic in which is very similar to the high volume clinic except that the volume isn't with patients.  The volume is with PT's.  An "I don't know you" clinic is one in which a person has a different therapist each time a they go in for a physical therapy treatment.  The patient is usually not informed at the time of scheduling that they will not be seeing the same therapist on a subsequent visit.  Imagine that you chose a primary care doctor.  When you go to the doctors office you know that you'll be seeing the doctor that you were expecting to see.  By seeing the same doctor you're able to build a relationship with the doctor.  By doing so, the doctor gets to know you well and is able to meet your needs in a very specialized way and in a very consistent way.  A relationship with confidence and trust is built.  This is the same way that physical therapy in my opinion should be practiced as well.  However, many clinics do not do this.  Instead, the patient is often placed on the schedule just to get you back in the door for your next visit at the clinic's convenience, not yours.  When you're placed on the schedule, you're also put with a different PT.  Here is an example.  A patient has been coming in at 10:00AM Monday, Wednesday, and Friday for the past 2 weeks.  Now all of a sudden for some reason, this time slot that they are used to is taken after two weeks out.  However, there is an option for the patient to stay with the current PT.  This is to schedule with the same therapist but at a different time.  But often times, the scheduling staff will keep you at the same time so that the rest of the schedule is not upset and when they do so the patient is scheduled with a different therapist.  In many cases, the patient will see a different therapist each subsequent visit.  This "I don't know you" method also benefits the clinic or clinic owner vs. accommodating the patient.  

The downfall of seeing a different PT each visit is quite obvious.  As with a patient's primary care doctor, a relationship is built.  Doctor and patient get to know each other and become comfortable with each other.  Same as with seeing a PT, trust and confidence are built as is a good plan of care for the patient.  Patient education is established with the PT, consistency with treatment is maintained with your PT, and good communication is established between you, your PT, and your referring physician.  When a new PT is tossed into the mix, it's like going to see a stranger and your plan of care is disrupted.  In addition, the PT does not know you or your status and your plan of care again is disrupted even further.

Here is a summarized list of con's with seeing an "I don't know you" clinic:
  • Most importantly, a patient's plan of care can be disrupted
  • Poor consistency of treatment
  • There is a chance of multiple diagnoses and change in philosophy of treatment
  • Education of ancillary staff regarding the patient is poor
  • Mixed educational messages often occur due to a PT's philosophy of practice
  • The patient's treatment can suffer due to the PT not having the full history of the patient prior to treatment
  • Of the different PT's, who will decide the progression of treatment and who will decide the appropriate discharge date?
  • Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time
My advice to you is to insist on the same therapist from each treatment session to the next!

Here is what you will want to know and ask when attending physical therapy:
  • Will I be seeing the same therapist each session?
  • How much time will my therapist spend with me?
  • Will I be under the care of physical therapy techs or aides during my treatment?
  • What part of treatment will the ancillary staff (PT techs, PT aides) be administering?
  • Ask to be scheduled out as far as possible so that you can stay with the same therapist and keep your therapy consistent
  • Pay attention to how much time you spend at your physical therapy clinic.  Then make sure that your bill matches the amount of time spent during your PT treatment.  Often times there is over billing.  Insurance companies do not have nearly enough time or manpower to audit physical therapy practices or medical practices in general 

On another page in my website, I mention that physical therapists do specialize in specific treatments or pathologies.  This is something else you will want to consider when choosing a clinic.  You will want to inquire about whether or not the clinic in question treats your specific injury.

As Usual, Good Health & Spirits To All

Brad Senska, PT, DPT, BS, ASTYM.


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