High insurance copayments drive costs up

By: Dale J. Buchberger, PT, DC, CSCS, DACBSP

National Physical Therapy Month (NPTM) is hosted by the APTA each October to recognize how physical therapists and physical therapist assistants help transform society by restoring and improving motion in people’s lives. Unfortunately, many New Yorkers do not utilize their physical therapy benefits because of outrageously high copayments.


Thousands of physical therapists from across New York are urging State lawmakers to curb the skyrocketing cost of patient copayments, which are threatening New Yorkers’ health while driving up the cost of the health care system. Joined by patients and advocates, members of the New York Physical Therapy Association (NYPTA) met with State legislators in an effort to end the unfair and outrageous practice of “specialty” copays, which can cost patients thousands of additional dollars and result in foregone treatment.

In many cases, patients who already pay for health insurance policies that are required by law to cover physical therapy wind up reaching into their own pockets to pay the entire cost, or close to it, of each physical therapy session. Their insurance companies pay little to nothing.

As a result, many patients skip physical therapy sessions or attend less frequently than recommended, risking re-injury, worsening their underlying condition and leading to more costly follow-up procedures that would not be necessary if a proper and timely physical therapy regimen could be afforded.

The NYPTA urged State legislators to support A.187, sponsored by Assemblyman Kevin Cahill (D-Kingston) and the identical Senate bill S.4870, sponsored by Senator John A. DeFrancisco (R-Syracuse). The bill would limit health care policy copayments to 20 percent of total reimbursement to the provider of care.


“Copays have become all-pays,” said NYPTA President Matthew R. Hyland, PT, PhD, MPA, CSCS. “These out-of-control copayments hurt patients by forcing them to stretch out or forego the physical therapy critical to their rehabilitation, hurt physical therapists by depriving them of business, and hurt all New Yorkers who help support the cost of health care through their tax dollars and insurance premiums. The DeFrancisco-Cahill bill is critical to bringing the system back into balance, making physical therapy affordable and accessible to all New Yorkers, and helping people live happier, healthier, and more productive lives.”

Managed care plans have been able to hike copayments by classifying physical therapy as a “specialty.” Currently, copays are not limited and may amount to the maximum collectable amount reimbursed to the physical therapist.


When a physical therapist agrees to be contracted or “in-network” with one’s insurance company, it means they agree to accept a lesser amount for services than what the therapist would charge someone without insurance.  For example, the maximum allowed amount that Excellus Blue Cross/Blue Shield reimburses is $50 for a regular P.T. follow-up visit.  That means no matter what the therapist bills for the P.T. session, the maximum they will be reimbursed is $50.  Depending on the insurance plan, some co-pays can be as much as $35, $40, $50 per visit.  In the case when a patient has a $50 co-pay, their insurance company is paying nothing to the provider and the patient has paid in full for that visit.  On top of that, some physical therapy treatments can require up to 10 or more sessions per month. That’s $500 per month in addition to your monthly premium! Meanwhile, the PT is seeing little to no reimbursement from the insurance company and the patient is paying more than 100 percent of the cost per visit.


A 2010 Brown University study of more than 1.5 million Medicare patient observations from 2001 through 2006, published in the New England Journal of Medicine, found increased outpatient co-pays increase hospital costs and may have adverse health consequences and result in higher overall health care costs (http://www.nejm.org/doi/full/10.1056/NEJMsa0904533). Similar studies by the University of Washington and the Intermountain Health Care System in 2008 on patients with lower back pain yielded similar conclusions, as did a project undertaken by Virginia Mason Medical Center in Seattle (http://blog.evidenceinmotion.com/files/wall-street-journal-2007-01-12-proactive-physicaltherapy-2.pdf).


Unfortunately, the DeFrancisco-Cahill bill has stalled in committee and because of the upcoming election will need new sponsorship and will have to be resubmitted. We will need to continue the fight each and every day in legislative districts around the state until this bill passes and New Yorkers have access to fair, reasonable, and affordable co-pays for physical therapy and other essential health care services. For more information: http://stophighcopays.com/


As Election Day approaches and candidates call you during dinner and knock on your door, ask them to pass legislation to force the insurance industry in New York to lower copayments and loosen the stranglehold that insurance companies have on small business and the middle class. Only your voice, loud and clear, will get this bill through committee.