LEWISTOWN - Effective Sept. 1, Highmark Inc. will be instituting a new physical medicine program which will require chiropractors and physical therapists to receive authorization from a computer program called Physical Medicine Management before performing extended services in physical therapy, occupational therapy or spinal manipulation.
According to the Physical Medicine Services Program Overview, authored by Highmark, if, after the initially approved eight visits, a doctor or PT believes a patient requires further treatment, the request must first be approved by the Physical Medicine Management Program designed by Healthways. The proposed treatment plan is processed through clinical algorithms to determine if the treatment plan is acceptable or even if the patient is eligible for further treatment. Only after receiving approval can treatment be continued.
"We are looking to reduce unwarranted variations in the delivery of care, protect patients, preserve benefits when members need them and avoid over-utilization which can lead to poorer outcomes," said Leilyn Perri, media representative for Highmark Inc. "As long as the procedures are medically necessary, members will have access to the important medical care they need, within the limits of their benefit plan."
At this time, the program will only affect Highmark members in insured groups in Pennsylvania and West Virginia. Physical therapists and chiropractors of Mifflin and Juniata County are expecting the program to create large amounts of paperwork and deny needed treatment rather than benefit the patient's wallet.
"The doctor will now spend more time filling out paperwork than treating patients," said Dr. Chris Hartley of Hartley Chiropractic and Rehab in Reedsville. "A computer can't determine treatment. It never went to school or met the patient. How could it? If further treatment is needed, the doctor knows it, not the computer."
There are too many variables in the treatment process for a computer to determine what is best for a patient, said Dr. Richard Klingensmith, of Klingensmith Chiropractic Center in Yeagertown.
"Unless referred by another doctor, there are times when a person comes in complaining of general pain rather than something specific," Klingensmith said. "It could take a number of visits to even pinpoint the cause and then a number more to design a treatment plan. Now, service providers have eight visits to quickly produce a cure or further treatment may not be approved."
Even if treatment is approved, the computer program could then limit the number of visits, Klingensmith said. If six appointments are suggested, the program might only approve two. Then it's up to the patient to pay-out-of-pocket for the remaining visits or they don't receive treatment, he said.
According to data gathered by Highmark, nearly two-thirds of members have their needs met and resolved within eight visits, said Virginia Calega, Highmark's vice president of medical management and policy.
"If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place," Calega said. "Highmark is protecting members from overutilization because overuse errors can cause harm and waste health care resources."
The problem with this program, and other health care reform, is that changes are made with broad strokes, said Luke Drayer, CEO of Drayer Physical Therapy, which has a location in Lewistown. Rather than targeting the people who are abusing health care benefits, the changes affect everyone regardless of actual service need, he said.
"This whole plan is flawed right from the beginning," Drayer said. "My company has roughly 300 physical therapists and about 100 of them will be affected by Highmark. That's a whole lot of change at once."
Drayer is also concerned about the appeal process. If a treatment plan is rejected, the doctor or physical therapist has a chance to appeal by presenting it to a group of local medical professionals chosen by Highmark.
"There is a chance that you could be discussing the issue with peers, in my case physical therapists," Drayer said. "But there is also a chance that you could be discussing physical therapy with a doctor that specializes in brain surgery. The understanding and communication isn't there."
Highmark believes the physical medicine program is a very reasonable approach for the company, provider networks and, most importantly, group customers and members, Perri said. A number of other Blue Plans and commercial insurance carriers have similar programs to help control costs, he added
"Utilization management is about quality and patient safety," Perri said. "We believe this policy is fair and reasonable."