Healthcare cost, Healthcare cost, Healthcare cost… the rhetoric seems almost endless regarding what benefits should be cut, what payments are unnecessary and how much fraud is occurring. I have been pondering the healthcare cost question for some time and have expressed my views to a few colleagues. It seems to me that the government wants to constantly focus on the symptoms of the problem (i.e. we are paying too much) without ever focusing on the root causes of the problem. While the problems are certainly multi-dimensional, I postulate that a base cause is the expectations that are created by our educational system.

Looking at Physical Therapy as a microcosm of healthcare in general, the last decade has brought a progression of the educational requirement to practice from a Bachelors degree, to Masters to a Doctorate. Basic economics/finance would tell you that you should only be willing to invest in a venture that yields a positive net present value (essentially, the cost paid upfront will be more than offset by the earnings that will be achieved subsequently). The expectations for compensation that are being created through the upfront educational costs are disassociated with the direction of reimbursement allowed by the 800-pound gorilla – Medicare. It’s probably not too popular to discuss this topic on a site that has one of its focuses as recruiting graduates however, it is a conundrum that students, employers and frankly the APTA, which has driven this educational progression, need to resolve.

Over the last decade the APTA has advocated for increased education to put Physical Therapy on par with M.D.s in the hope of expanding self-referral and minimizing therapy’s tie as a referred service overseen by another medical professional. While the organization has been successful in driving towards the DPT standard and has put some wins in the self-referral column, it has been decidedly less successful in affecting an even more important component – reimbursement. One could say they are fighting an uphill battle given that Medicare is trying to reduce costs but if that is the case, why do you raise compensation expectations at the same time that reimbursement is declining?

In the last six months, therapy has been hit by MDS 3.0 (which slid the cost structure higher by significantly reducing concurrent therapy and student involvement), RUG IV (which “re-balanced” the per diem nursing/therapy weighting of the overall reimbursement back to nursing) and MPPR (Multiple Procedure Payment Reduction, which reduces reimbursement for multi-unit/multi-discipline therapy treatments). Downward pressure on reimbursement, upward pressure on costs due to the debt service and/or investment return expectations of students and practitioners – an interesting cocktail to contemplate. I welcome your thoughts and comments on these competing directions.