Charging more for insurance clients...

[Physiobase]

Below is a quote mentioning the APA's position on billing for fee compensatable clients

The APA's stated position is market rates plus the additional cost of servicing compensable patients.

What is the rest of the world doing? I would rather not see them at all unless they pay up front. Then they can organise reimbursement directly through their insurer. I feel this would be the best position to take.

How do others feel? Will the insurance companies actually pay more for you to treat their clients than what you charge as a standard fee? I would have thought many would have just said, "no way"! I am very aware that this is common practice in doctors surgeries and also generally in the USA. It however doesn't wash at present in the UK.

This is a great area of interest and perhaps a few national association representatives could post official statements about their position in this area of debate.

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[MrPhysio+]

Hi
Hot topic. The APA has a number of position statements. The one regarding adding extra (calculated at 12.5% in 1995 for the extra work necessary foir Insurance patients - now considerably more due to Insurer interferences),is a good one. It is, however, a great pity that the APA is less than forthcoming in representing therapists who argue the APA line. Currently, the Insurers in Victoria Austyralia pay well below the market rate, let alone extra for the additional paperwork, claims officers hassles, and delayed payments, plus extra invoicing for 'lost' paperwork.
The APA also recognises in policy that therapists can charge a 'gap' fee to make up the difference between the Insurer pittance and the market rate, however the latest figure I have seen is that only 8% of Victorian therapists charge a gap fee. I am one. The APA does not support me well, and in fact seems to hinder me at times.
A concerted marketing effort from the APA to all members encouraging them to charge gap fees would be a great help. Unfortunately, the Victorian Branch of the APA seems to have close ties to the Insurers, and they try hard not to upset them, for some reason.

In general terms, if Insurers wish to add to costs by increasing compliance requirements, they should be expected to pay above, rather than below, market rate. The more requirements, the greater the increased cost. If they require increased educational standards etc, they pay for the increased professionalism and service received. You do not pay for a Kia and expect to drive a Mercedes.
Physiotherapists need to make their feelings on this topic known to their Associations, in very strident terms, or nothing will change. Sitting back expecting our 'representatives' to properly put our views forward when they do not know our views is an exercise in futility. My views have been put forward for 15 years, however there are not enough people willing to speak up, despite holding similiar views to mine.
Thanks for raising the topic. Managed care based on Insurer models is actually decreasing patient care quality, simply to increase profits and bonuses for Insurers. Victorian WorkCover made $1.2 Billion profit in the last financial year, with the Premier stating that he is placing an extra $155 million back into the system. A joke - as none of this is earmarked for the therapists providing the treatment skills, currently at discounted rates!
I am passionate regarding this topic, and it is good that is receiving an airing.
MrPhysio

[DMITSCH]

2003 - The APA challenge the prevailing view that charging a gap fee to obtain a market rate was illegal in Victoria - 0% of physio's charged a gap, instead they accept the fee set by the compensible body.

2005 - on the back of APA communication, 8% refuse to be a price taker and charge a gap.

Interesting what happens when you add the full facts.

[Physiobase]

8% isn't much! Does that suggest there needs to be better member communication and awareness on this issue? Should it not be 80%?

[alophysio]

Hi.

I am not defending the APA position on this matter nor am i from Victoria.

However, I can understand why a lot of physios don't charge a gap fee (even though we should).

My practices don't charge a gap fee (even though I think we should). The reason why is silly in the end but when you first start out, all your patients are precious and you are trying to build a relationship with local doctors, who by law send you these patients (as opposed to the patients coming in off the street).

I have now got a very good reputation amongst the doctors that I don't have to worry about this. However i have not changed this method of charging as CTP - basically car accident patients - makes up <2% of my total patients.

If i were to change i would go to making the patient pay up front the normal private patient fee ($60 Initial and $50 Subsequent) - something I want to raise but haven't got the guts to do yet. I know the PBA/APA would like to see us raise our prices above the Worker's Compensation rate but it is so easy to keep things at the same rate. Ideally I believe that Physios should be worth over $120 per hour so $60 subsequent should be the go but it represents a 20% increase on my current price...

[Physiobase]

I agree it can feel risky to increase prices. I only did mine because staff wanted a raise. I told them the only way was to increase prices and that if they coulod still command the increased price then that wuld be fine. So they put up the prices (15%), the clients were fine about it and everyone did better. Price whilst begin a factor, is not the best way to run a practice. The longterm security through word of mouth and clinical results breeds a practice that grows more slowly but has a much more solid structure, less financial exposure and in the long run will be happy to accept yearly price increases of at least 5%.

Again the idea of setting a basic fee above the work cover amount is something the APA need to ask members to take on board as a group. A large marketing and awareness campaign would be paramount in it's implementation and acceptance. Unfortunately we are dealing with the private practitioner, a rare fragile community that doesn't usually get to much of the budget. In the UK it gets very little indeed.

[DMITSCH]

On the question - Should it not be 80%?

That's purely dependent on ecconomics. If large health purchasers pay extremely well then the number could be 0%. If they pay rates well below that which the market will accept then I'd expect a high figure. In Victoria, I suspect (entirely on anecdotal evidence) that the figure should be higher however other factors holding physiotherapists back such as concern about the reaction from GPs and patients are more of a factor then awareness at the moment. Importantly, if this number increases substantially over the coming year or so, it will present some challenges to large purchases who try to argue that their prices are in line with community expectations.

[MrPhysio+]

The ongoing discussion on this topic is very welcome. Mr Mitschs' comment re 'the full facts' is interesting. The general physiotherapy community is not very well informed on this issue, and Damians comments on this site should be better reported through the Association, representing members more fully. The Physiobase responses are appropriate to the frustration felt in the field. Damian Mitsch represents Physiotherapy Business Australia, and I know that this Special Group has trouble being represented fully by the Victorian Branch of the APA on some of these types of problem.

It is unfortunate that Damian seems to continue sarcastic asides against my comments, but it is good that others can maintain the focus to the actual issues, and ask pertinent questions of him.

Alophysio (on the previous forum before this topic was set up), noted the way the APA fudged comments or did not respond on requests for specific educational subscriptions to journals.

Over the years there have been many occasions where the APA has ignored my written requests, or failed to answer the question asked, rather giving generalised policy. Often the answers, when received, contradicted previous answers or responses from various staff. A failure in understanding and applying policy.

It is the above (and many other examples I could specify), problems that cause me frustration with the APA, Vic Branch.
eg Members have been asked not to place abbreviations after their qualifications such as M.A.P.A. (Member Australian Physiotherapy Association), and one Queensland member wrote to complain regarding the policy, with David Malone responding quite forcefully. This is a problem, as an APA representative has until at least recently used such abbreviations after his name on official documentation (Damian Mitsch). Consistency from our representatives should be maintained, with leadership by example.
My concerns re the gap payment issue are related to the APA supporting its own policy more forcefully, and better educating all members (not just PBA members), rather than my saying the policy does not exist. As one of the 8%, it would be easier to deal with the Doctors, Insurers, and patients if the uptake was greater. The uptake percentage will not increase until the members are better educated, thereby reducing the fear inherent in charging the fee. This is a Victorian issue, as Victoria has the worst compensible payments compared to other States (approximately 20% below the real market rate, not counting the 12.5% and above compliance costs). These are the facts.

I would not have charged the gap payment if it was not legal to do so. I was one of the members who strongly argued for the APA to start doing something. The policy in existence today is a start, but needs to be supported.

I propose that the APA Vic Branch send out a letter to all members clearly arguing the policy and Damians views, unequivocally stating that the APA will support members who decide to charge a gap fee, with the support being active to the degree that an APA representative can be allocated for the public, Doctors, or Insurers to contact for the policies verification.

Once this is done, gap charging uptake should increase. The APA cannot specify the amount of the gap to be charged, therefore no price fixing issues arise with the ACCC.The increased uptake will then place more pressure on the compensible bodies to recompense therapists at a more sustainable level.
Phew! Sorry for the long post, however I feel that justification for my position needs to be supplied, given the attack being made upon my integrity. Thanks for reading.
MrPhysio

[DMITSCH]

I think a focus on the issues would be good. However I must again correct factual inaccuracies.

The MAPA post nominal was withdrawn after concern was raised that it could mislead uninformed patients into believing that a member holds a Masters level qualification when that was not the case. In fact, definitely in WA and most likely in all other states it would be grounds for referral to the registration board as it contravenes the registration act. It might also result in action by the ACCC under the trade practices act as it may be likely to mislead. The APA within its own code of conduct can not have a policy that might create a breach of law.

MAPA was replaced by a member logo depicting that a person is an APA member - members are strongly encouraged to identify themself as a member. I understand the policy was changed in the late 90's (maybe 1996 - it was well before my time) and members were given a good period of time to change their stationary. I believe the deadline was the end of 2002 and an article reminding members was run at that time.

Further, I'm not, nor have I ever been a member of the APA and thus I've never used the post nominal "MAPA". I hold a Master of Business Administration and thus use "MBA", a graduate diploma in aged services management and thus use "GDip ASM" and I'm a fellow of the Australian Institute of Company Directors and thus use "FAICD". I'm currently working on a Doctorate of Business Administration and I plan to use the prenominal "Dr" and postnominal "DBA".

I don’t think that it's misleading for people to believe that I hold a qualification that I do actually hold (Sorry if this sounds sarcastic but it's frustrating to have to correct facts after each post).

To get back to focusing on the issues I repeat "In Victoria, I suspect (entirely on anecdotal evidence) that the figure should be higher however other factors holding physiotherapists back such as concern about the reaction from GPs and patients are more of a factor then awareness at the moment". The phenomena of uptake has been well studied and documented as following an S curve and the argument that we can change this in a free market by simply creating more awareness is fundamentally flawed (PS. My doctoral thesis covers innovation uptake). Awareness is only one factor that affects uptake. Physiobase picked up on another key factor - organisational (or in this case professional) culture. Anxiety amongst Physiotherapists over the issue of charging this client group a fee is high (and even higher for refusing to treat DVA patients) and the only way this anxiety will be overcome is if they see their colleagues (being the early adopters) patient load has been unaffected by gap billing. I'll add that the more we discuss strategy in public forums, the easier it is for compensible bodies to pre-empt moves by the APA to put the profession in a strong position - this is why there are compensible body committees in each state that represent the members. The Victorian CBC contains mostly private practice physio's who reflect similar concerns but also have discussions around strategy.

I'm going to conclude here by saying that I'm here to offer the occasional comment on the business of physiotherapy and I'm finding that I'm spending too much time simply responding to inaccurate statements made by a MrPhysio. If MrPhysio has comments about the business of physio that are worthy of debate, I’m happy to offer the occasional comment but I’m not planning on responding to further inaccurate musings on the APA. Sorry guys – I’ve got work to do.

[MrPhysio+]

Here we go again!
Thanks for vindicating my views, Damian. Being a fellow of the Australian Institute of Company Directors (FAICD), is not a qualification. The FAICD is the same as using MAPA, which we are not permitted to use, as physiotherapists. I know that Damian is not a Physiotherapist, however if regulatory bodies are concerned with professional misrepresentation when a person uses an acronym for membership to a body, the same reasoning should apply to all.
Using qualifications after your name was not the issue I was raising. Am I wrong to point out the contradiction in Damians behaviour and statements?
Again, I am defending my position against unreasonable attack.
MrPhysio

[Physiobase]

OK guys, this is now getting a bit off topic. Perhaps you would care to start a seperate one on the use of MAPA, which I still use in the UK. I thought they made a change because it was short for Map of Tasmania, which some found a bit crass? I think we now know the APA position on charging more and perhaps why many don't. Seems a bilateral problem, APA and their members.

However it seems education would assist. I don't believe we had one hour dedicate to running a practice when I did my undergrad course at Sydney University. It really should have a whole semester at least dedicated to business management as this is a definite career path in all healthcare sectors, public or private. 8o

[MrPhysio+]

Thanks Physiobase for the discussion. Most points have now been made, given the tit for tat exchange. forum participants will now have a good understanding of the though processes involved with Associations and members. If others feel the MAPA issue requires further input, I look forward to the opinions expressed.

Two days ago I had a discussion with a highly placed WorkCover representative in Victoria. She informed me that the Authority would not reimburse the cost of nedles used for trigger point dry needling, as acupuncturists do not charge separately for these items, and it would be a contradiction if physiotherapists were reimbursed. She also made the surprising admission that she thought that private patients were not charged for such extras, therefore WorkCover should not have to pay either.

Two points: Acupuncturists only undertake acupuncture, and their service provision charges include their needles. Physiotherapists undertake a wide variety of techniques, and with extra training this can include trigger point dry needling. If physiotherapists restrict some techniques for private patients only, as Insurers will not fund the cost of consumerables, then there will be two levels of treatment, with compensible patients being the poor cousins. This in turn will affect treatment outcomes, necessitating more treatments for a given outcome, or poorer outcomes for compensible clients. Both examples will cost Insurers more money in the longer term, if they are to carry out ethical care. Therapists cannot therefore be responsible for the poorer outcomes.

Secondly, private patients do pay for consumerable items, plus they pay a higher rate for treatment than the compensible bodies do for treatment of their patients. It is unfortunate that the Insurers seem so insulated and out of touch with reality, and that this dissonance is encapsulated within Insurer policy.

The WorkCover lady also commented that people on Insurance generally took longer to return to work and required more treatment than private patients. This is a spurious argument, and compares oranges with lemons.
If Insurers pay less for services than private patients, Physiotherapy businesses can respond by using new graduates or less experienced staff - causing delays in return to work and increased frequency of treatment (see Damian Mitschs posting).

Patients without compensible insurance cannot always afford to self fund, and may receive less than optimal treatment frequency, and return to work earlier than they should due to economic considerations.Such patients may then carry an injury for much longer, with the injury becoming chronic, and affecting them much longer than those receiving may adequate treatment due to nsurance.The Insurers keep records of treatment frequency and treatment costs for their clients, however they do not have access to self funded patients, and therefore cannot do comparisons - and should never base policy upon assumption.

A person injured at work through no fault of their own expects that they should be rehabilitated at no cost to themselves, as it was a failure of the employer to provide a safe work environment, with adequate duties. Disability caused by work is the reason for the Insurance schemes being set up. A person injuring themselves outside of work takes the rehabilitation responsibility and cost upon themselves if it was their own fault.
Managed care organisations cannot have it both ways. If they want top professional care for their clients, they have to pay. If not, they must take responsibility for poorer outcomes due to interference via low remuneration and therapist treatment decisions being over ridden.
More comments welcome.
MrPhysio