Healthcare professionals confront a range of ethical and regulatory issues in today’s ever-changing practice environments. Doing what’s best for the patient is often influenced and, at times, compromised by external factors, including rules and regulations associated with third-party payment systems.1,2 Medicare, Medicaid and commercial insurance carriers have established conditions of participation and fiscally driven regulations, such as payment caps that often direct practice parameters and may affect patient care and outcomes. Ethical issues that create dilemmas between what is and what should be may confront practitioners. Optimal care for a given patient may be compromised by limited benefits and changing regulations.
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Explore This IssueFebruary 2015
To confront these dilemmas, physical therapists need to know their available options and develop strategies that consider best practices within the confines of contemporary payment systems.
A 56-year-old man is referred to physical therapy (PT) for sciatica, degenerative disc disease and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the past month, he has lost his capacity to bend, lift and carry during activities of daily living and work. While registering at the Outpatient Rehabilitation Center, he learns that his Medicaid benefits provide for a PT evaluation only, without any follow-up services.
Upon completion of the initial examination, the physical therapist considers treatment options given the identified impairments and loss of function, including manual therapy for the lower lumbar spine, stabilization and strengthening exercises for the low back and trunk, and instruction in a home exercise program and proper body mechanics. The physical therapist recommends follow-up twice a week for four weeks. However, given the limitations of the patient’s insurance benefits, these additional treatments will not be covered.
How would you proceed? Ask the patient to pay out of pocket for optimal care, or proceed with only the evaluation that is covered? Should the patient be offered free or discounted services because it seems like the right thing to do?
Physical therapists practice in a wide range of delivery system models, including academic, hospital-based, home health and private office practices. Physical therapists are also members of a wider healthcare team for patients with rheumatic diseases and musculoskeletal conditions. Other team members may include rheumatologists, orthopedic surgeons, nurses, occupational therapists, social workers, pharmacists and psychologists, to name a few. Rules and expected behaviors and priorities vary across these systems and cultures and are subject to change.