An insurance company changed the rules.

Years ago, they decided to cap the reimbursement amount for a physical therapy visit.

Regardless of the value of that appointment,

Time spent,

Or the treatment/care provided,

They thought it best to cap their reimbursement.

They would pay up to a certain dollar amount – $75 – for one visit.

After that,

You could continue to treat the patient,

You just weren’t going to get paid for your time or services.

The decision was ‘based’ on some cross-regional data comparison.

Arguably, the decision could be seen as made for the best interest of the company’s profit margins.

The third-party payer system on which the healthcare system operates already had its limitations and restrictions on reimbursement, authorization to treat, what services will or will not be paid, etc.

This cap put a major devaluation of physical therapy services at such a low number. It markedly impacted the value of your service, business profitability, and the level of quality care provided.

Our clinic practice model was best served with one-on-one care; working with one patient at a time. After our own statistical analysis, we deduced that one more major insurance company capped like this one would jeopardize the business.

The insurance company was sacrificing their patients’ care,

And the livelihood of those providing their patients’ care,

Not for the care of their customers (patients),

But all for the sake of a higher profit margin.

Again, this wasn’t the first or only experience of an insurance company’s focus on profit over their patients or practitioners.

For some reason, this one stuck out to me.

I was rattled.

If one more of the bigger insurance companies followed suit and our ability to do it our way was sunk.

We already weren’t profiting much with one-on-one care.

In order to stay afloat with additional reimbursement caps, we would have to double or triple book patients when possible.

Reduce the quality of care,

To keep the lights on.

Reduce the joy of our profession, our practice,

To keep the practice alive.

We were talking contingency plans.

Reactive plans.

Double-booking patients.

Reducing number of physical therapists,

Finding a smaller space to lease,

Cutting all ties with insurance companies and returning to cash-based treatment only.

We were having a few potential scenarios, and one very real scenario

Dictate how we do our jobs.

How we perform our craft,

How we find our fulfillment.

We weren’t having the control/power/freedom to gift the craft and joy we wanted.

Over a few years, we tried various changes to our practice model,

In reaction to this ordeal –

Patient technicians,

Overlapping patient care (when permissible),

Altering the daily schedule to allow for more patient slots,

Working a PTA into the treatment plan.

We landed back on an iteration of our original care model,

Maybe with a renewed sense of our value,

and direction.

More physical therapists were added to help generate more revenue,

(cover overhead and increase profit)

‘Product line’ was increased with diverse options to generate more revenue

(yoga, cash based Non-PT products, taping, injury prevention program, etc).

Adding more clinicians gave a temporally-limited success.

A spike in numbers, but not sustained.

It lacked certain measures like appropriate incentives for marketing and community connections to grow and make those staffing additions sustainable.

There was a challenge to cross-market and connect patients and other community members to the cash-based products as they did not necessarily have an immediate connection to the brand/style of physical therapy other than they both dealt in health.

Viability, generating revenue, and growth were driving the decisions.

Yes, we were also driven by the style and quality of care we desired to offer.

But that was not necessarily at the forefront guiding decisions.

Mission and vision were seen as sections of the start up business documents that existed.

But they didn’t pervade the atmosphere of the company.

(Eventually, a reboot of those items was in the works as I left the company).

The company was set out by the owner to fulfill his high school dream of opening a business

and to be a community hub for health and wellness.

Which is a good endeavor. Not many attempt to make a dream a reality.

That endeavor was able to provide me an experience unique to that business.

I/we needed a unifying principle.

I/we was/were lacking a focal point that extended beyond the clinic,

That was bigger than anything achievable,

But served as a generative source that inspired and called me/us forward.

It is not very fulfilling for someone to say ‘I am fulfilled by fulfilling my boss’s high school dream’.

All that to say,

An insurance company’s decision and

A physical therapy clinic’s reactionary measures

Opened my eyes, but to more than just those two realities.

Over time, I was learning about how we have been shaped and constrained by longstanding conventions.

Health was being sold as a product. Achievable and possess-able.

A product discounted by third-party payers.

A product we were selling.

And we were also giving that same message to patients:

‘Come to us for a quick fix’ – ‘get back to pain free activity’ – or some iteration thereof.

We all were reducing health down to an attainable, finite product that was achievable.

Meaning, once you get ‘better’ (get ‘healthy’), you were done. Fixed.

You were finished playing the game.

I don’t train, get in shape for a marathon, stop training, and then stay in shape.

Once I run the race, I am not done training.

I am not able to run 26.2 miles, sit around for 6 months and then get up and run another marathon because I ‘attained’ a level of fitness months ago.

It wanes.

It is a habit.

An ongoing process.

You do the work. Continually.

You enter the flow.

You grow.

You get better.

You have issues.

They resolve.

You keep going.

Flow.

The same holds true for health.

Being ‘better’ does not mean you are done tending to your health.

Health is also an ongoing process, continually needing investment and attention.

Cars need regular maintenance.

Tires rotated.

Oil change.

Spark plugs.

Timing belt.

Brakes, rotors.

Transmission fluid.

Coolant.

Headlights.

Filters.

gaskets.

Blinker fluid.

Battery.

And that is just a car.

How is a human body no different?

I was finding difficulty selling health as an achievable, conclusive product.

Big corporate providers turning into ‘big box’ stores for health services.

Insurance companies ‘setting the market price’ for health services (but instead of high prices on seafood, they’re lowering the reimbursement rates while concurrently raising premiums and opportunities for patient-out-of-pocket responsibilities – all to increase corporate profits).

Healthcare providers reducing health to an attainable commodity to be sold.

Patients seeking care with the aforementioned understanding that health can be fixed.

Patients reduced to a means for profit.

Providers and patients reduced to pieces in a game for big corporate profit.

Yes, profits are essential to sustaining healthcare businesses. Revenue keeps the lights on. The services provided are valuable. Providers deserved to be paid appropriately. Their skill and time holds remarkable value. Health is important. Profit is important. I am opposed to neither. I question what happens when profit is held higher than health.

Health is not a static, achievable status.

Health is an ongoing, dynamic process.

And I believe that health can be redefined for patients thusly.

We can call patients to participate in their health. Not look to fix it.

For providers to redefine health for their patients,

Providers must first redefine their professional roles.

Reinvest in the dynamic nature of our ‘practice.’ Not fixing a static problem.

For providers to reinvest in their practices,

We must first redefine ourselves.

Reinvest in the nature of who we are,

What gifts we have.

And how we can find joy and fulfillment each day.

We have the opportunity to be the change from within the system.

We don’t start by targeting the heads of industry, or the like.

We have the power and control to start with our own treatment rooms,

Our teams,

Our companies,

Our communities.

We can become the leaders we are looking for.

by: Dr Adam Fujita DPT