AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.
Featured topic and speakers
Is physical therapy covered by insurance? What is a PT cap? What happens when you can't do physical therapy? Does Medicare limit physical therapy?
Our guests are Courtland Keteyian, MD, president/CEO of the Mosaic Clinically Integrated Network and medical director for occupational health at Henry Ford Jackson Hospital; Sam Porritt, founder and chairman of the board of the Falling Forward Foundation; and Atul Patel, MD, a practicing physiatrist, member of the governing board for Falling Forward, and a board member and treasurer of the American Academy of Physical Medicine & Rehabilitation. AMA Chief Experience Officer Todd Unger hosts.
- Watch AMA Update for health care news for physicians, residents and medical students.
- Not a physician? Join the Patients Action Network.
- See how Falling Forward is helping patients fully recover from catastrophic medical events (e.g., strokes, traumatic brain injuries, spinal cord injuries).
- Read the AMA policy on therapy caps.
- Learn more about the AMA Health System Program.
- The AMA is your powerful ally, focused on addressing the issues important to you, so you can focus on what matters most—patients. We will meet this challenge together. Join us.
- Learn more about our AMA advocacy priorities, including:
- Reforming Medicare payment
- Fighting scope creep
- Fixing prior authorization
- Reducing physician burnout
- Making technology work for physicians
Speakers
- Courtland Keteyian, MD, president and CEO, Mosaic Clinically Integrated Network; medical director for occupational health, Henry Ford Jackson Hospital
- Sam Porritt, founder and chairman of the board, Falling Forward Foundation
- Atul Patel, MD, a practicing physiatrist; member of the governing board, Falling Forward; board member and treasurer, American Academy of Physical Medicine & Rehabilitation
Transcript
Porritt: I'm able to walk today, work, drive a car, mow my grass, hike in the mountains, all things that wouldn't have been possible if I had hit a therapy cap and my rehab had stopped. And I watched my fellow patients while I was going through rehab.
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about therapy caps in health plans and how they can create barriers to patient care. Joining us are three guests who are working hard to remove those barriers. Dr. Courtland Keteyian is president and CEO of the Clinically Integrated Network at Henry Ford Health and medical director for occupational health at Henry Ford Jackson Hospital in Jackson, Michigan.
Sam Porritt is founder and chairman of the board of the Falling Forward Foundation in Lawrence, Kansas. And Dr. Atul Patel is a practicing physiatrist and member of the governing board for Falling Forward in Leawood, Kansas. He's also a board member and treasurer of the American Academy of Physical Medicine and Rehabilitation. I'm Todd Unger, AMA's chief experience officer in Chicago. Thank you all so much for being here today.
Porritt: Thank you, Todd.
Dr. Keteyian: Thank you. Happy to be here.
Unger: Well, Dr. Keteyian, my first question is for you. Why don't we just start with a brief introduction to the concept of therapy caps. What are they? And which health plans have them?
Dr. Keteyian: So in a given year, roughly about a million people experience severe injuries. So spinal cord injuries, strokes, other brain injuries. And those types of injuries require for really the best outcome to have extended periods of rehabilitation. Insurance companies, most insurance companies followed what was a therapy cap rule that was placed by Medicare in 1997.
And so what that means is that insurance companies will essentially arbitrarily—there's no science behind this—limit the amount of therapy that an individual can provide after one of those catastrophic injuries, which obviously, inhibits what their long-term potential and outcome is.
So it was in 2018 that an exception process was actually successfully implemented with Medicare. And so that's actually really been an important concept for us to be able to make sure that folks are getting the right type of care that they need. Unfortunately, most health plans still have not followed suit with Medicare and implement a cap process.
Unger: Well, it's pretty clear then how therapy caps could quickly become a barrier for patients. Sam, talk to us a little bit about how much of an impact they can have.
Porritt: Yeah, so, Todd, thank you, again, for inviting me to be a part of your podcast. This issue of therapy caps is one that most people in the outside world really know nothing about. And Courtland did a great job of summarizing the history on the therapy caps, starting back in 1997, in Medicare, and then today being in virtually all health plans offered by all carriers.
So to your question about the impact that they have, Courtland mentioned the over a million people a year having the neurological injuries like brain injuries and strokes and spinal cord injuries. A recovery from an injury like that is a long, slow process. The brain doesn't heal quickly. The nerves in the nervous system don't heal quickly.
And so regaining function that's lost to those kinds of injuries, regaining function is a long, slow process in rehab. And rebuilding your body, regaining the ability to talk, regaining the ability to care for yourself, do activities of daily living, and ultimately being able to live independently and do things like going back to work or going back to school, all of those things are dependent on rehab.
And again, it's a long, slow process. And the rehab journey is step by step by step. And Courtland used the perfect word, I think, in describing the therapy caps. The current caps are arbitrary. It's an arbitrary limit. It has nothing to do with medical necessity. And the exceptions process that he also talked about that was implemented in Medicare, that exceptions process is all about medical necessity of giving people who need continued rehab that opportunity to continue on as long as it's medically necessary.
Unger: Are a lot of people hitting these caps?
Porritt: So in the over a million people a year that Courtland mentioned having the neurological injuries, virtually all of them are hitting their caps because today's insurance plans across America, the caps are in 98%, 99% of all plans offered in America.
Unger: I'm curious what inspired you to take on this movement.
Porritt: OK, that's the perfect question. I come from a very different background. I'm not a health care professional like Courtland and Atul. I was a healthy guy working in the corporate world for many years. And in 2011, I suddenly had a spinal cord injury.
And my injury happened when my wife and I were on vacation in Italy. I was taking a picture with my phone. I wasn't paying attention to where my feet were. And suddenly, I lose my balance and I fell off a 15 foot wall. And instantly, I'm paralyzed from belly button down. I've got a spinal cord injury.
So I go from this fantastic vacation in Tuscany to I'm laying on the ground paralyzed. And I have no idea what my future is going to be. And I knew nothing about rehab. And I knew nothing about therapy caps. Like most people in the world, I'd never heard the term before.
Well, Todd, unknown to us, we had the 1% policy that didn't have a therapy cap. So I was paralyzed from a spinal cord injury. I needed a whole lot of rehab, and I got it because we had this insurance policy—again, we didn't know—that had no limit on rehab.
So to your question about what inspired me is I went through that recovery process. I did rebuild my body. I regained my life. I'm able to walk today, work, drive a car, mow my grass, hike in the mountains, all things that wouldn't have been possible if I had hit a therapy cap and my rehab had stopped.
And I watched my fellow patients while I was going through rehab. I watched them all run into their therapy caps. And one by one, they were sent home in a wheelchair or unable to talk or unable to do normal things.
So ultimately, that's what inspired me is I got a gift in many ways of the uncapped insurance policy. I saw that rehab works. It worked for me. And it works for other people. So we started this nonprofit organization that's addressing this issue now.
Unger: That's a really powerful story. And—
Porritt: Thank you.
Unger: —as you point out, you did get a gift. And what's amazing is that you really took on this cause to help those that weren't as fortunate in that regard by establishing Falling Forward. Dr. Patel—
Porritt: And—
Unger: I'm sorry.
Porritt: And Todd, if I could. Sorry to interrupt you. I should mention, like any nonprofit, we raise money. And what do we do with the money? We pay for people's rehab when their insurance stops. When they hit their cap and the insurance benefit ends, we pay for their rehab to keep them going.
So my story is powerful. I'm happy to tell my story. But the best news is we now have over 200 other stories. Of over 200 people that we funded their rehab, they have recovered. They've gone back to school. They've gone back to work. They're back being parents. They're living independently. They have their lives back. But it's only because they got the rehab that was medically necessary and they really deserve.
Unger: Well, Dr. Patel, can you talk a little bit more about the work of Falling Forward and how it's helping patients recover?
Dr. Patel: Yes. Thank you for inviting me to be part of this podcast. Yeah, Falling Forward, our main objective, as Sam mentioned, is raising money and helping people. But as Courtland mentioned, there are a lot of people out there. And we're only helping a small group of patients right now.
But our main goal or another mission is to try and do advocacy work. And through advocacy, we want to try and make sure that insurance companies other than Medicare are also now covering and allow for the exceptional process for patients to get more therapy.
The caps really make a big difference in the outcome of these patients. And I'll use an analogy. Like going to school and getting educated helps a lot with how well you do in life. People lose their function. And if they get rehabilitated or get schooled again, they can really get back on their feet or back on—being much more functional and a productive human being.
Unger: Well, thank you very much. And speaking of advocacy, Dr. Keteyian, I've known you through your work and active involvement in the Integrated Physician Practice section at the AMA. You're heavily involved in advocacy work and particularly on this issue. You helped to pass a resolution about this issue at AMA's Interim Meeting last year. Tell us a little bit more about what that resolution called for.
Dr. Keteyian: Yeah. Thanks, Todd, for that lead in there. It's very, very proud to partner with a number of other folks who are disability advocates within the AMA and the House of Delegates. And to really elevate this concept of therapy caps. And so clear recognition that the Medicare exception process really was the gold standard we should be trying to strive for nationally for all health plans.
And so the positioning of the resolution was to basically request that the AMA advocate specifically to align that exception process across all health plans. And so that's also where just speaking to the audience here, a lot of physicians, a lot of people that have influence in their respective states, this is an issue that really can be taken locally and work at the state level as well to influence the legislative process and try to get that exception consumption process really implemented at plans across the country, not just with Medicare.
Unger: That makes a lot of sense. Both federal and state level advocacy is so important. And certainly, the AMA will be advocating there for both. Dr. Patel, if patients want to speak out on this issue as well, what should they do?
Dr. Patel: Yeah, that's a great question. I also want to just thank people like Dr. Keteyian, organizations like the Falling Forward organization and the American Academy of PM&R working towards advocacy and helping all these people with disabilities.
And to answer your question, yeah, what can patients do? I think sometimes patients are afraid to ask for help, but they need to talk to their providers, especially their doctors, and tell them, "Hey, can you please do a peer to peer or a write a letter to my insurance company so that they can maybe make an exception and give me more therapy?" So I think that's the first thing. Patients should feel comfortable. And physicians and providers should invite them to ask those questions and help them out as well.
I think the other thing that patients can also do is push back themselves. Sometimes insurance companies are very willing to listen to their clients. And if the patient is also complaining and asking, "Hey, this is my situation, I need help," or if it's a family member who's writing for the patient, then they can explain the situation and do that.
The other thing that is many of these people work for private companies at one time and they get injured. So there's an HR department. They can have their HR department become aware of what's going on and tell them and see if they'll fight for them and get the exception.
One other thing is many people, when they sign on for an insurance, they don't even think about that they're going to need rehab. They're looking for things like oh, what dental coverage do they have and all those other things, but they forget about rehab. So start looking at that. And I think companies need to do a better job at looking at what the rehab coverage is for their patients.
And finally, I think Courtland was alluding to even patients, I mean, they should write to their congressmen and tell them about—make them aware of the situation.
Unger: Yeah, we know those personal stories are just so important in making change. Dr. Patel, Sam, Dr. Keteyian, thank you so much for joining us today to raise awareness about this issue and for all the work that you're doing to help patients. To support the AMA's advocacy efforts on this issue and more, if you're a physician, you can become an AMA member at ama.assn.org/join.
That wraps up today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
Subscribe to AMA Update
Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.
