A former patient comes to my mind when thinking of today’s topic, a father, in his mid to late ’30s, having tweaked his right shoulder after participating in a Brazilian Ju-Jitsu class. Before treating him, he had been seen by another physical therapy outfit for an average of 15-20 minutes of one-on-one time each session for 13 sessions and had not made any impactful improvement over less than two months. Prior treatment included a lot of manual soft tissue work and strengthening exercises. A previous MRI showed a rotator cuff tear of the same shoulder. He could not raise his arm fully both in the front and to the side without pain. To him, surgery to repair that rotator cuff looked like a very likely possibility.
It took two sessions to get him to be 75% better by teaching him self-treatment exercises to the neck that led to pain-free movement of the shoulder. We also filled in the gaps of postural stability and proper shoulder strengthening exercises. His primary cause of irritability was coming from his neck despite the pain location and findings of a rotator cuff tear on MRI. He decided not to opt for surgery based on his return to everyday life. The exception was Brazilian Ju-Jitsu which he chose not to resume. He continued managing independently, having learned how to progress on his own effectively.
The above example is a display of two things: one, money and time being saved through focused one-on-one, hour-long treatments that were cash-based, and two the McKenzie Method being fast and thorough in determining that the source of the pain of the shoulder was coming from the spine and not the shoulder.
But Cash-Based Physical Therapy Is So Expensive
The subheading above is often one that I hear and thought by many to be true, but is it? Often, the obstacles for a patient seeking effective, quality, one-on-one care are cash-based physical therapists who provide that type of care at a higher price. These clinicians are typically out-of-network (for non-Medicare patients they are not fully covered by your insurance plan) with higher upfront costs for treatment. It can be challenging to see the long-term value and savings of a cash-based therapist initially. However, what becomes clear is the realization that what is accomplished in three visits or more can be completed in one visit by investing in a quality one-on-one care, cash-based physical therapist.
According to a relatively recent article by verywellhealth.com, the average health insurance co-pay (payment for services that usually contribute to your deductible) for physical therapy usually runs from $25 to $35 for each visit, sometimes reaching the upward cost of $50 to $75. Early in my career, I had worked in jam-packed outpatient clinics, seeing anywhere between 18-24 patients a day. The therapy provided was not at the level it could have been because of the time constraints and inability to focus on each patient entirely. In addition, the norm was to schedule for 3x/week to meet productivity goals, with patients MAYBE getting 15-20 minutes of true one-on-one time with their therapist as multiple patients were being seen at once. Even in the hospital outpatient setting, the norm is to schedule treatments for 2-3x/week with patients frequently not seeing the same therapist which means more visits and money spent because of lack of continuity. That being said, patients are looking at paying upfront costs of $50 to $225 ($25 x 2, $75 x 3) per week in co-pays, and if they have not met their deductible (the amount paid first for covered services before your insurance plan starts paying, this can range between $500 – $10,000), they will be spending even more out of pocket for less one-on-one time, less precision in care, and more visits.
Let’s take the example from above about my previous patient. Based on the before mentioned co-pay amounts, 13 visits meant he spent anywhere between $325 (13 visits x $25) to $975 (13 visits x $75) in co-pays alone upfront with the other clinician and strongly was leaning towards rotator cuff surgery. Had he gotten surgery, he would have had additional physical therapy for recovery, which would have been covered by insurance as the surgery cost would have met his deductible. However, look how much time it would have cost him. It would have been 13 visits and counting and a probable surgical procedure on his shoulder leading to another six months of rehab. All that time and effort would have been performed and he may still have had unresolved shoulder pain because the neck may not have been treated after surgery. The surgery would fix the rotator cuff tear but not necessarily his shoulder pain. If he had been seen by us earlier (not to toot our own horn), we probably would have reached the same return to normal daily function at a price of roughly $270 (an evaluation and treatment session); actual savings to the patient of at least $55 to a maximum of $705 ($325 – $270, $975 – $270).
Now did we fix his rotator cuff tear? No. We just determined it was not the cause of his pain and lack of function. He was satisfied with the result and was independent in self-management with a little bit of guidance. Seventy-five percent of symptomatic, atraumatic, full-thickness rotator cuff tears may be treated successfully through conservative treatment.2 This scenario is an example of imaging not necessarily describing or telling the whole story of why someone is having pain.1,3,4 While not initially made aware of by most people, this scenario and many others like it, display how ultimately costs are saved when you decide to invest in the right cash-based pay clinician that you can trust.
But Isn’t The Above Example Just One Instance Where It Worked Out For The Patient?
My answer to that is yes. It is just one example. However, what path do you believe will lead you to resolve your pain and injury more quickly? Is it the one-on-one time with a clinician you see for maybe 15 to 20 minutes whose attention is shared with at least one other patient each visit, OR focused one-on-one time with a clinician you see for 60 minutes each visit who likely has higher-level training? These busy physical therapy clinics either have therapists fresh out of school who have limited experience and training or their therapists are time compromised; leading to less thorough care. These are common practices for these facilities. I would know because I used to manage one. Their goals typically lean towards maximizing profit ahead of what is maybe appropriate and needed by the patient. If your goal is to get well (pain-free and learning how to stay pain-free) as quickly as possible, the option to get you there appears to swing more and more heavily towards a cash-based physical therapist.
But I Have Great Insurance That Provides Full In-Network Coverage! Why Go Cash-Based?
Great question. A cash-based therapist likely has higher-level training and is better nuanced in patient management. They know and have the time to push the right buttons to help you overcome obstacles in motivation or in learning styles. Ultimately, those details get you to being pain-free and independent faster. Along with highly focused care, their guidance typically extends beyond the hours of the treatment, being available to connect with you at extended hours, even on the weekends to ensure you stay on task towards getting well. That is free added value for the patient that is so beneficial and can be the difference maker in making breakthroughs in recovery. All that being said, your excellent insurance plan may reimburse significantly for out-of-network outpatient physical therapy.
I recently had a patient who had a comprehensive insurance plan through her work that covered 80% of out-of-network fees for services. In the end, she paid approximately the same amount as a patient who would receive less focused time and treatment at a busy clinic. Not only was her pain resolved quickly, but she received the proper skills and knowledge to stay well independently. If a recurrence happened, she now knew exactly what to do. Teaching patients how to truly stay well independently is often unclear more than you think outside of the cash-based setting. Clinicians at super busy clinics spending 15-20 minutes with patients one-on-one don’t have the time to entirely focus on that aspect secondary to trying to maintain maximal productivity at all costs, treating multiple patients at the same time.
I Have Medicare Coverage. Does Cash-Based Physical Therapy Even Apply To Me?
Cash-based outpatient physical therapy applies to Medicare-covered individuals who want high-quality, high-level trained one-on-one care from a physical therapist who happens to be a non-participating provider of Medicare. A non-participating provider of Medicare essentially is allowed to collect the fees for treatment at the time of service in full. By law, anybody treating individuals covered by Medicare for medically necessary conditions have to submit billing forms to the Centers for Medicare Services (CMS) for Medicare Original or Medicare Supplement plans. For Medicare Advantage plans, the billing form is sent to your insurer of the plan (Blue Cross, United Healthcare, etc.). Reimbursement checks covering at least 80% or the total amount (depending on your plan of coverage) are then sent straight to the patient within 30 days from either CMS or the Insurer of your Medicare Advantage plan. This allows individuals covered by Medicare to attain highly trained clinicians who are non-participating providers. Essentially you are exchanging payment upfront and reimbursement later for an upgrade in care and skill of the cash-based physical therapist leading to faster results. The expectations of getting back to life faster with cash-based pay physical therapy services are no different between the Medicare patient and the non-Medicare patient. The only added step is for the physical therapist to submit your billing form for you, to ensure you get reimbursed, WHICH FEDERAL LAW REQUIRES. No extra work is needed on the Medicare patient’s part.
At first appearance, it can seem like cash-based physical therapy services for your pain or injuries have no benefit or do not benefit you financially. However, looking a little deeper tells a different story. Many of us who are cash-based clinicians do so because we want to provide top level-care we would want for ourselves, our family, friends, and neighbors. We want to provide treatment as we believe how it should be provided, with faster results, building relationships through greater focused one-on-one treatment times, and using our extensive training to help you without limitations. Our goal is to provide clear guidance to promote independence in pain-free management while saving you money and time. If you are ready to get well quickly and most importantly, learn how to stay well independently, make an appointment here today!
Jeff Lum PT, MPT, OCS, Dip. MDT is a physical therapist and owner of Mobile Spine Specialist serving the North Austin Texas communities, including Cedar Park, Round Rock, Georgetown, Leander, and Pflugerville. You can learn more about how he helps individuals overcome pain and improve mobility. To make a connection, reach out to him.
Reference List:
1) Connor, P.M., Banks, D.M., Tyson, A.B., Coumas, J.S., D’Alessandro, D.F., 2003. Magnetic Resonance Imaging of the Asymptomatic Shoulder of Overhead Athletes: A 5-Year Follow-up Study. Am J Sports Med 31, 724–727.
2) Dunn, W.R., Kuhn, J.E., Sanders, R., An, Q., Baumgarten, K.M., Bishop, J.Y., Brophy, R.H., Carey, J.L., Holloway, G.B., Jones, G.L., Ma, C.B., Marx, R.G., McCarty, E.C., Poddar, S.K., Smith, M.V., Spencer, E.E., Vidal, A.F., Wolf, B.R., Wright, R.W., 2014. Symptoms of Pain Do Not Correlate with Rotator Cuff Tear Severity: A Cross-Sectional Study of 393 Patients with a Symptomatic Atraumatic Full-Thickness Rotator Cuff Tear. The Journal of Bone & Joint Surgery 96, 793–800.
3) Heidar Abady, A., Rosedale, R., Chesworth, B.M., Rotondi, M.A., Overend, T.J., 2017. Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study. Journal of Manual & Manipulative Therapy 25, 235–243.
4) Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins S, A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS), J Man Manip Ther., published online, 2019.
5) Sears, Brett. “Anticipating Physical Therapy CostRehab With and Without Insurance.” VeryWellHealth, 25 August 2021, https://www.verywellhealth.com/physical-therapy-cost-5194917
