Sam Porritt was enjoying a relaxing vacation in central Italy with his wife when one misstep changed his life.
His attention was on the stunning scenery. As he used his cell phone to take photos overlooking a patio terrace, he lost his balance and fell off a 15-foot wall. The fall injured his spinal cord, paralyzing him from the belly button down.
"I go from this fantastic vacation in Tuscany to laying on the ground paralyzed. And I have no idea what my future is going to be,” said Porritt, founder and chairman of the board of the Falling Forward Foundation, which is a nonprofit organization that pays for people's rehab when their insurance stops.
Porritt also had no idea how fortunate he was. He spent nearly two years in intensive physical therapy, and that care helped him regain his life. His insurance covered all of that physical therapy.
Less than 1% of policies nationwide offer similar coverage.
About 1 million people each year suffer severe injuries to their spine or brain, said Courtland Keteyian, MD, 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. Those people, like Porritt, require extensive physical therapy.
Henry Ford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
All other policies have therapy caps that create barriers to patient care. Porritt joined Dr. Keteyian and Atul Patel, MD, a physiatrist and member of the Falling Forward Foundation governing board, in a panel discussion to talk about those caps and the harm they create during a recent episode of “AMA Update.”
The history of therapy caps
Most have therapy caps from insurance companies that limit how much physical therapy insurance will cover.
"Insurance companies will essentially arbitrarily limit the amount of therapy that an individual can [have] after one of those catastrophic injuries, which obviously inhibits what their long-term potential and outcome is," Dr. Keteyian said. "There's no science behind this."
The therapy cap rule was initially enacted by Medicare in 1997, and most insurance companies enacted similar policies. When an exception process was implemented with Medicare in 2018, the insurance companies did not follow suit, Dr. Keteyian said.
The benefits of physical therapy
Porritt witnessed the impact of these therapy caps firsthand. That physical therapy helped Porritt get his mobility back. Today he can drive a car, mow the lawn and hike in the mountains. Many of the other patients who were in physical therapy with him were not as fortunate, he said.
"While I was going through rehab, I watched them all run into their therapy caps," Porritt said. "And one by one, they were sent home in a wheelchair or unable to talk or unable to do normal things."
Prior to Porritt's injury, he'd never heard of therapy caps. He admits that the fact his insurance policy was in the 1% without such limits was pure luck. But he doesn't think that the chance to undergo life-saving rehabilitation should be left up to chance like that.
"The brain doesn't heal quickly. The nerves in the nervous system don't heal quickly," he said. "Regaining function that's lost to [serious] injuries is a long, slow process.
“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," Porritt added.
That's why Porritt launched the Falling Forward Foundation, which has helped more than 200 people fully recover from life-altering severe injuries.
"They've gone back to school, they've gone back to work, they're back being parents, they're living independently," Porritt said. "They have their lives back, but it's only because they got the rehab that was medically necessary."
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Fighting for others’ needs
Dr. Keteyian is actively involved in the AMA Integrated Physician Practice Section and a strong advocate against therapy caps. In fact, he helped pass policy at the 2024 AMA Interim Meeting to update advocacy efforts to ensure health plans with therapy caps implement an exception process similar to Medicare's exceptions.
"The Medicare exception process really was the gold standard we should be trying to strive for nationally for all health plans," Dr. Keteyian said.
This policy received overwhelming support and was co-sponsored by the American Academy of Physical Medicine and Rehabilitation, American Academy of Orthopaedic Surgeons and the American College of Rheumatology.
"The positioning of the resolution was to basically request that the AMA advocate specifically to align that exception process across all health plans," Dr. Keteyian said. "This is an issue that really can be taken locally and worked 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."
The Falling Forward Foundation also does similar advocacy work, according to Dr. Patel.
Part of that initiative is to help educate patients about their rights and their need to speak up for themselves.
Dr. Patel said patients should feel comfortable talking with their care team about needing more therapy.
"Sometimes patients are afraid to ask for help, but they need to talk to their providers, especially their doctors," he said. "And physicians and providers should invite them to ask those questions and help them out as well."
Dr. Patel also encouraged private companies to better examine the insurance plans they offer to help make sure their employees have therapy coverage should they need it.
“Companies need to do a better job at looking at what the rehab coverage is," he said. "They're looking for things like what dental coverage do they have … but they forget about rehab."
Porritt will never forget about rehab. His goal now is to make sure anyone who needs physical therapy can get it so they, like him, can get their lives back.
“I got a gift in many ways of the uncapped insurance policy," he said. "I saw that rehab works. It worked for me, and it works for other people."
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