Pelvic Physical Therapy or Wellness: Where's the Line?
Is there a divide between physical therapy and wellness? Prevention? Maintenance? If so, where is it...and if not, how has this idea invaded our profession?
Many in the pelvic health profession are concerned about where the line is between 'skilled physical therapy' and 'wellness' services.
Ultimately, this is a much broader question. It calls into question what we believe our role is for our patients. Check out the full podcast 'sode on this topic (on Apple Podcast or wherever you get your podcasts)
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There is no legal divide between physical therapy and wellness
We've often heard the assumption there is something 'illegal' about conflating physical therapy and wellness services. This flows from our state practice act. And while these do differ state-to-state, we've yet to see a state where wellness, exercise, preventative services, maintenance or training is not allowed.
So it's certainly not 'illegal' to do wellness services.
Our governing body (the APTA) SUPPORTS wellness services
If you thought the distinction between skilled physical therapy and wellness services came from our governing body, you would be (understandably) mistaken.
In fact, the APTA has consistently been in favor of physical therapists providing these types of services.
"Physical therapists play a unique role in society in prevention, wellness, fitness, health promotion, and management of disease and disability" - APTA, 2019
"Incorporate concepts of prevention, wellness, fitness and health promotion with every patient or client as appropriate" - APTA, 2019
It doesn't come from common sense or ethics
So if there's no legal distinction and our governing body supports wellness and prevention, it must be a moral issue or another universal reason for this divide. Right? It certainly doesn't seem that way to us. Wellness is defined as "the active pursuit of optimal health." That seems a worthy goal for each of our patients. Not just resolving their most immediate complaint, but offering all of our knowledge and skill to help them achieve optimal health.
The 'divide' between skilled physical therapy and wellness comes from insurance companies The sole reason we have a sense of a distinction between physical therapy and wellness is because of insurance companies. More specifically, because of insurance companies' bottom line. Remember, insurance companies are for-profit institutions. They made money by cashing premium checks of their members. And they keep that money by not paying it out to providers. The more they keep, the more they profit. And the more they profit, the more their shareholders and officers make. This sets up a fundamental conflict of interest. The patient wants to get better; their insurance company wants to minimize costs.
So insurance companies create a distinction between services they will (sometimes) pay for, and ones they won't. This is where the difference between physical therapy and wellness comes from in our field.
Not from the law. Not from our governing body. Not from our patients. From insurance companies looking to maximize their own profits.
"Over-Utilization" of Services
This term 'over-utilization' of services has crept into our vocabulary - and unfortunately the curriculum of many of our schools - from insurance companies.
Does anyone actually feel we're ever in danger of over-utilizing physical therapy?
I would contend we chronically under-utilize physical therapy services. Especially in pelvic health! Only a fraction of those who could benefit from pelvic rehab actually come in.
And many of those who do are discharged in 6, 8, 12 visits because of limitations of their insurance company when they haven't met their goals.
In pelvic health we should be helping our patients throughout a lifetime. Through menstrual health, sexual health, pregnancy, post-partum care, menopause and any other challenges to pelvic health. Not just to minimize or treat problems, but to optimize pelvic health and function. Practical Takeaways
So, we've recognized our distinction between 'physical therapy' and 'wellness' comes solely from the desire of insurance companies to make more money. What now?
1. We can refocus on our patient. We won't go wrong if we do our best to add value to our patient's life. With whatever tools we have. Wellness, prevention, maintenance and more are supported by our governing body and allowed under our laws. So it can be a decision between us and the patient.
2. If you work in an insurance-based practice, understand the limitations. When insurance is paying for service they do get to set the rules. They can make a distinction and refuse to pay for some services. Recognize you're often stuck between the interests of your patient and the interests of their insurance company. And if we lead with clinical honesty and let our patient know what we really believe they deserve we've done our job. (Also, if you're looking for a job in a cash practice, check out the Pelvic PT Rising Hiring Board, where our Business Mentees have posted jobs across the country!)
3. If you're in a cash-based practice, there is no distinction. Decisions can be made with just you and the patient. Document honestly. Give your patients a superbill with what you did that day. If the insurance company has a problem with what you're doing they can always deny it.
If we get back to focusing on the ways we can transform the lives of our pelvic health patients without arbitrary distinctions, we'll be providing the kind of care our patients deserve.
Nicole Cozean, PT, DPT, WCS
Jesse Cozean, MBA
Co-founder of the Pelvic PT Rising and the Rising Podcast.
Jesse uses his business experience to help pelvic health business owners start and grow their practices so they can build a practice that truly works for them. From website design, SEO, conversions, marketing, finance and money mindset, he wants to make the process of owning your own practice easier and fun.