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Variations in medical care – it happens in PT, too.

There’s yet more evidence that treatment patterns vary significantly across providers.  Today’s evidence comes courtesy of two academic institutions and Medrisk, Inc. (consulting client) which reported significant differences in the type and duration of physical therapy provided to workers’ comp claimants.

The study looked at several variables contained in billing data: location of service, duration of care, type of care, and other data points; the data was case-mix adjusted.

There are several key takeaways:

  • corporate physical therapy centers billed for more visits and more units per episode than other practice settings.
  • there was a “large difference in treatment utilization between geographic regions regardless of practice setting, diagnosis, body-part treated or surgical intervention”
  • these corporate centers billed for “a lower proportion of physical agents indicating a greater use of those interventions supported by evidence-based guidelines (exercise and manual therapy) compared to other practice settings.”

These findings were consistent across diagnoses and after controlling for surgical v non-surgical cases.

Let’s look at the second takeaway.  It should come as no surprise that the type, volume, and delivery of medical care one gets varies a lot from region to region.  While one would like to think that the care we get is based on science, in many instances the care you receive depends more on where your provider was trained, the local standard of care, and the personal opinion of the treater than what has been scientifically proven to work.

That said, the final point – that treatment in line with evidence-based medical (EBM) guidelines is more common in corporate settings is…intriguing.

Increasing the use of treatments for workers comp claimants that are in line with evidence-based medical (EBM) guidelines is a primary goal of many payers, regulators, and other stakeholders; WCRI’s just-published review of state workers’ comp regulations provides ample evidence of this trend.  While there could well be reasons the use of treatments supported by EBM were more common in corporate-based settings, the discussion in the report appears to address some of the key factors; delay in initial treatment, severity, and acute v chronic status.

Let’s be sure to recognize that these findings are general, overall, and based on statistical analysis.  Undoubtedly there are clinic-based, private, facility-based, and other PT practices that are quite focused on EBM and rigorous in their application.  And, to reiterate, there may well be sound and valid reasons for the differences noted by the stdy authors.

What does this mean for you?

1.  Good to see research focused on this key area of workers’ comp; with 15 to 20 percent of medical dollars spent on physical medicine, the more we know, the better.

2.  Payers should talk to their network partners to find out what type of care their PT providers deliver.  If they don’t know, find a network that does.

6 thoughts on “Variations in medical care – it happens in PT, too.”

  1. Joe-

    I think it should be noted that physical agent modalities are reimbursed (at least in the state in which I practice) at a significantly lower fee schedule than that of therapeutic procedures. This invariably will lead to more practices, especially corporate-owned centers who have “billing specialists” in the ear of their therapists, to utilize and bill for the higher-paying unit. A conclusion that these corporate-owned PT clinics perform more evidence-based care should be made with caution.

    The finding that is most note-worthy, in my opinion, is that there is a higher per-visit episode of care in the corporate PT centers, which would be a marker of potential over-utilization.

    1. David thanks for the comment

      I’m not sure I follow your logic. Businesses do not and cannot just pass along taxes – or any other cost- to their customers. If they could they would never be concerned with cost cutting. In fact, while some costs can be passed on others cannot. The current economic environment offers a Plethora of examples, with farming just one; coal is another.

      I’m also puzzled by your statement that all taxes are eventually paid by consumers. That is not the case for medical devices in many instances nor for concrete for roads or steel for machines. While much of the costly eventually work it’s way thru to an individual consumer, I’m not aware of any research that supports your assertion.

    2. Kevin thanks for the comment.
      While your comment that better billing practices and not better care may have influenced the data accessed by the researchers may be true, I’d suggest that is an assumption and not based on verifiable data. If you are aware of any such data I’d be happy to review it.

      I’m sure that many independent practices provide excellent care and bill accordingly. And most practices have become quite skilled at billing, particularly those where the PTs are the owners. There’s a counter argument to be made here; owner-operators care more and bill smarter.


      1. Thanks for the thoughtful reply, Joe. I am not aware of any such data that you are referring to, I speak solely from experience (which of course holds no clout in academia). My main point was that using purely data from billing practices may not be the best way to assess EBM compliance. There is research being conducted by our field on a practitioner-based survey (June 2013)…

  2. Joe, I see that you are the featured speaker at the CWCI annual meeting in San Francisco in March. I am looking forward to hearing your remarks.

    Susan Fisch

  3. I am not sure what a corporate owned center actually is, but regardless, as a practitioner and clinical researcher my suggestion after reading a summary of this study is as follows. The observation that there is variation in physical therapy practices should not be a surprise, in fact, in many cases is explainable, and in the absence of an identified “best practice” standard based on diagnosis and adjusted for patient co-morbidities, should be encouraged so we can continue to explore which method works the best (comparative effectivenss research). EBM is not about developing cloned protocols in health care-either in medicine or rehabilitation. It is more about having a rationale that has some science (the more the better) behind it, but apart from the science there is always the art of practice which needs to be considered. Who ultimately decides which treatment combinations are most effective? The answer, of course, is the patient or the recipient of the treatment. My point is, the focus should be on patient outcomes-since they will ultimately define what is working, whats best and who the cost effective providers are. As a payor I would not be interested so much as to which provider type treats the longest (utilization) as much as which provider type or provider characteristics are predictive of superior outcomes at a particular utilization level. In other words, you can treat a little longer, just show me that I have received incremental value in the form of superior patient outcomes. I would argue that it is preferable to treat longer-or more intensively if better outcomes are achieved. Why? Patients with better outcomes are less likely to have to return to therapy for the same condition that wasn’t completely treated the first time around. I presented this type of data to a large insurance carrier in our region about a year ago as a result of insurance mandated and arbitrarily imposed therapy limit thresholds. Sorry for the length of this post.T Marovino

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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