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Physical therapy can be too much of a good thing: Study

Physical therapy

Often touted as a treatment for injured workers, excessive use of physical therapy can be a significant cost-driver for workers compensation payers and can impede return to work, experts say.

“Physical therapy is a wonderful thing; it’s just when it’s abused,” said Dr. Ed Bernacki, a professor of population health with the Dell Medical School at the University of Texas at Austin, who co-authored a study finding that the costs associated with 15 sessions or more of physical therapy can be close to double to costs of ten to 14 visits.

The study, published in August’s Journal of Occupational and Environmental Medicine, provides data sourced from 192,197 comp claims in Texas between 2013 and 2017. The report concludes that excessive physical therapy — 15 or more visits — can increase claim costs more than other well-known cost drivers such as comorbidities, opioid use and legal involvement, and can keep claims from closing.

One of the most unexpected revelations of the study was that excessive physical therapy has a greater influence on costs than does legal involvement when an injured worker consults with a lawyer, said Nina Leung, assistant professor at the medical school’s Department of Population Health.

“Legal surprised me most because of how strong of a predictor it is of (high comp costs) in other workers compensation studies,” she said.

Experts say there are several explanations for the study’s findings.

Limited communication between medical providers who order physical therapy for recovery, physical therapists, injured workers and claims handlers is one possible reason for the overuse of physical therapy in some cases; generic guidelines; and poorly trained physical therapists could all drive overuse and costs, according to experts.

“There are parts of the system that are broken,” said Jeff Weeks, partner and chief development officer at ARC Physical Therapy+ in Overland Park, Kansas, whose business is 60% comp patients. “You should have a pretty good idea of what the prognosis is on the third or fourth visit, but not all operate as such.”

Kate Farley-Agee, Chicago-based vice president of network products for Coventry Workers Comp, said the industry is aware that excessive physical therapy is a concern and that “we have gotten better at it but there are certainly improvements needed.”

Changes to the industry over the past few years—more nurse case managers, utilization reviews and robust preauthorization guidelines—have helped bring about change, she said.

Delaying physical therapy is another factor in prolonged use of physical therapy, said George Furlong, Tampa, Florida-based, senior vice president managed care outcomes at Sedgwick Claims Management Services Inc.

“The interesting thing we are finding is (the correlation between) when physical therapy starts and outcomes; if you dig in (the data) you may find physical therapy starts later, two to three weeks out (after the injury),” he said, adding “that delay leads to higher claims costs and longer disability and longer physical therapy.”

The delay is attributed to “a combination of factors,” said Mr. Furlong. “It could be a lack of communication” between doctors and claims manager and worker “on getting things scheduled” and the worker’s “ability to tolerate pain and the psychosocial factor of pain avoidance.”

Mr. Weeks said delay in care is an issue — that often a physical therapist doesn’t see an injured worker until up to 100 days after an injury. “This is conservative care gone wrong,” he said of the common practice to delay such medical interventions and tests to see whether the patient can recover without them.

“They start the case off wrong in the beginning,” he said. “I would advocate that if quality care was provided early on, it would have a significant impact on duration and level of function at (maximum medical improvement.”



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