Good PT Is Great Rx

In MedRisk’s report, one workers compensation trend is using conservative care to avoid more costly treatments. What have you seen in that space?

When possible, we opt for conservative therapy first. One initiative we have embarked on is the use of a pre-treatment consultation to help with this. It’s about 20 to 30 minutes where we listen to the patient, talk about conservative therapy and different ways to deliver it that make it convenient for the worker.

The conversation includes a couple of things. Patients should understand they have a prescription for physical therapy [PT] for their condition, which a majority of patients end up having. We let them know that most people don’t need to jump to surgery—that imaging and conservative treatment is effective.

We perform a psychosocial screening. This is an opportunity to uncover things that might be a barrier for someone returning to work. It’s an evidence-based tool that helps get to things like a history of anxiety or depression, things that were there already but might be a hurdle for them getting back. Someone might have a comorbid condition or have trouble getting to therapy. We had one injured worker who was prescribed pool therapy, but she had no interest in putting on a swimsuit and getting in a pool.

It’s the discovery component, and there are a lot of carriers out there that have this in their process. If we can identify some of these factors up front, we can let the nurse or treating physical therapist know, and they can cover it during treatment.

The study shows that workers comp patients have more PT visits and more modalities done at those visits than on the medical side. Is that because of the focus on avoiding surgery?

Yes. A majority of workers comp is going to be musculoskeletal in nature, and we are utilizing PT as a way to avoid surgery and reduce opioid use. A lot of what’s coming over is chronic and low back pain, and sometimes we can use modalities like heat and cold packs. We do what we can to keep people out of the operating room or from becoming addicted to drugs.

MedRisk has seen a drop in visits per case and time spent in those visits in recent years. To what do you attribute this trend?

Generally, there are more advanced surgical interventions that are driving speedier recovery time and less PT after surgery for things like carpal tunnel. There are also some more aggressive postsurgical rehab protocols which can get patients in and out of PT faster.

There is also a huge push in workers comp toward value-based care. You are seeing it in general health and PT a lot. Those industries are far more outcomes-based in recent years, partially because of Medicare. And that is helping move PT and workers comp into that mindset as well. There are already some provider groups, like orthopedic surgeons, that have some value-based arrangements that do include physical therapy. It’s headed there; what happens in general healthcare tends to come over to workers comp as well.

Was there anything new or unexpected you learned from this survey?

From a treatment perspective we aren’t surprised to see more physical therapy visits and modalities in the industry. There is more and more evidence supporting conservative treatment over surgery. It works well for meniscus tears, low back pain, and rotator cuff injuries. There is a lot of talk that different [passive] modalities are not as clinically effective [as active ones], but they are a huge component of pain and inflammation management.

How does MedRisk interact with insurers?

We work with third-party administrators, carriers, and large employers to manage their physical therapy. Our role is to help them find the right provider and ensure the injured worker is going to providers that are in-network. We provide them some insights into treatment strategies; sometimes the workers comp adjuster or nurses might not be an expert in PT. We have our own proprietary set of evidence-based guidelines to follow for treatment that is appropriate and medically necessary.

When a referral comes in, we make sure it is the appropriate prescription and compare it with our guidelines. Then, we provide oversight to make sure the patient is staying on track. If we feel it’s not going well, we have a group of in-house PTs to work with the treating physical therapist, adjuster, nurse and physician to get it back on track. The payments are in the hands of the insurer—we just give guidance.

How does MedRisk set up its provider networks?

We have a large network of physical therapists, occupational therapists and chiropractors. We don’t own any of the clinics, so we can be objective in the treatment management. We do a lot of data mining regarding provider networks and the practices. We place patients with nearby providers but, more importantly, ones that would be right for their injury. We have a lot of data and an algorithm that shows one PT is excellent at treating post-op rotator cuffs and others at other types of injuries. And we go over practice patterns of the providers and meet with them regularly to make sure they are using evidence-based guidelines and getting the outcomes we expect them to get.

You mentioned an uptick in the use of telerehab. How much care do you do in that

We have been using telerehab for more than two years, and it makes up about 18% of our books. We have a lot of people on it, and it has been very successful. We only use it if a patient is a good match, which means they have a willingness to try something different and be compliant.

So telerehab is more appropriate for some patients than others?

If someone has missed appointments, we will sometimes reach out to see if they can’t get there and offer telerehab instead. It’s been a great additional option for injured workers. Those that make it through the finish line have really benefitted from it; they have fewer visits, but they are very engaged.

Surprisingly, it’s not necessarily the younger population or those that are tech-savvy who like it. The group where we have the largest percentage of folks using it is around ages 45-54. They probably embrace it because they can do it from almost anywhere—on the worksite, in hotel rooms.

We can offer it if someone is willing, has their head in the game, is motivated and has the right technology. And there’s some fluidity between the clinic and video. We can offer the option that is convenient for them. People have an average of 30 minutes of dedicated time with a PT and can also go to a portal for education and videos. Those that go through a hybrid model will have fewer visits per claim.

We are also working on providing on-site, telemedicine PT services at an employer’s location. A business that has a lot of volume could be supplemented with a video terminal so patients wouldn’t miss time from work. All they need is a room that is private with some space to move around.

Keep in mind there is a pretty intense screening process that has to be done by a physical therapist before someone can even consider using telerehab. We don’t use it for things like head or jaw injuries, and they can’t have an active infection or inflammation and must have stable balance.

As an industry, your focus is clearly on pain management. What have you learned about reducing the use of opioids and addiction?

We are often able to determine at-risk employees [for addiction] from the initial consultation. If the injured worker has a pretreatment consultation and a PT chat to go over things, the likelihood of getting an opioid prescription decreases by 65%.

What do you wish brokers better understood about workers comp?

Some of our messaging to brokers and employers is about making sure they are aware that PT for workers comp is a big part of their medical spend—about 20% generally. It’s really important, especially in industries with higher rates of injuries, that brokers are placing employers in programs that are strong on the PT side. They need big networks that can cover large geographic areas and are focused on value and are outcome oriented. Brokers shouldn’t overlook this area, because it can drive other medical spending down in places like surgery and opioid prescriptions.

They need to seek vendors with high-value service that are employing PT appropriately. The difference between functional recovery and disability is appropriate referral to physical therapy. It has to be timely and evidence-based and collaborative, and it should be informed by psychology as well so they know if there are other issues going on.

Physical therapy also has to be outcome based. They can’t just send people to PT without goals. They need to make sure the injured workers take responsibility for their compliance or it won’t work. There is a whole process around that, and you have to have those components.