Outpatient Rehabilitation:
Managing the Most Costly Medical Conditions

By Michael Weinper, PT, MPH

Employers looking for ways to keep their workforce healthy and productive and their medical costs in check would do well to focus their efforts on the employees most likely to need expensive care. An employee with a chronic condition such as heart disease, diabetes, or hypertension uses significantly more health services than the average person (see Table, "The 15 Most Costly Medical Conditions," below). That means more hospital stays, more prescription drugs, and more emergency room visits. Workers with back pain, arthritis, and other muscle and joint pain cost American employers more than $60 billion a year in lost productivity–and most of those costs are the result of sub-par job performance, not absenteeism. ¹

One cost-saving solution for employers is to choose health plans that include outpatient rehabilitation services. Outpatient rehabilitation therapists, including physical and occupational therapists, have much to contribute in the way of disease management, injury prevention, and health maintenance. Studies have shown that placing injured workers in physical therapy early in the course of treatment is linked to fewer doctor visits, earlier discharge from care, fewer restricted workdays, and fewer days away from work.² For a look at how physical therapy works in nine different conditions, from heart disease to cancer, and from mental disorders to physical trauma, see the sidebar "How Rehab Helps," below.

Rehab: Timing is everything

Recent medical advances allow more people to survive serious illnesses such as cancer and heart disease. Rehabilitation helps them recover from those illnesses, regain strength, and return to productivity. Providing rehabilitation therapy soon after surgery helps patients become ambulatory to avoid further complications. There is evidence that "pre-habilitation" offers benefits as well: Physical therapists at the University of Missouri found that exercising prior to surgery can condition the body and speed recovery after an operation.³

In all settings, the timing of rehabilitation is important: The earlier stroke patients begin rehabilitation, for example, the sooner their brains "re-wire," and the better their chances of recovery.

Therapists educate patients with chronic conditions on how to adapt to their limitations, maximize their productivity at work, and achieve a healthy lifestyle. Regular exercise in and of itself has been shown to help alleviate coronary artery disease, hypertension, obesity, diabetes, and osteoporosis. Therapists offer approaches to weight management that include an exercise prescription to burn calories as efficiently as possible.

The economics of ergonomics

Employers can reduce their workers’ compensation costs as well as their medical costs by using industrial rehabilitation therapists to prevent and treat workplace injuries. These therapists:

• identify ergonomic risk factors that can contribute to injury;

• implement control measures, such as adjusting work surfaces to minimize awkward postures; and

• educate workers on how to prevent injuries, e.g., offering healthy back care classes, or seminars on avoiding cumulative trauma disorders such as carpal tunnel syndrome.

Some companies also use therapists for jobsite analysis and pre-placement screenings of job applicants.

If employees are hurt on the job, they need prompt physical therapy to facilitate a safe return to work. At the same time, therapists can educate workers on breaking dangerous habits, such as improper lifting, and help them learn to move in new ways to avoid re-injury.

Teaching healthy habits

About 93 percent of U.S. companies now offer some kind of health promotion program, up from 89 percent in 1996.⁴ Encouraging wellness is a win-win for employers and employees because people who are in good shape to begin with are less likely to suffer from injuries and illnesses, and to recover more rapidly if they do.

Physical therapists are uniquely qualified to run wellness programs because they have experience and knowledge about how the body moves, and in-depth training to assess problems and deal with participants’ limitations. The programs may include onsite exercise classes and supervised use of gym equipment as well as health screenings and workshops on issues such as weight loss and smoking cessation.

Selecting A Rehabilitation Therapist

When choosing rehabilitation practitioners, the private practice physical therapy setting is the most cost-effective venue in which a patient can receive care. Studies published in the New England Journal of Medicine⁵and the Journal of the American Medical Association⁶ have shown that patients treated by independent therapists received more quality care and needed fewer visits than patients treated by therapists who work in physician-owned clinics.

A therapy network of private practitioners should offer broad geographic coverage for easy patient access and provide a wide range of services including physical, occupational, speech, hand, and pediatric therapy. The network should also cover specialty areas such as workers’ compensation injuries, ergonomic assessment, and geriatrics. Physical therapists specializing in the care of older patients deal with conditions such as osteoporosis and arthritis and offer special services, including balance training, fall prevention classes and "Fit After 50" wellness programs.

Ideally, the network should require that providers meet strict membership criteria and stringent credentialing requirements that surpass those required by the National Committee for Quality Assurance (NCQA).

Aided by the expertise of rehabilitation practitioners, employers can help their employees manage and recover from costly illnesses and conditions, promote wellness and safety for all workers. Bottom line: Effective control of health care costs, and increased worker productivity.

REFERENCES

1. Stewart WF et al: Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290:2443-2454.

2. Zigenfus G, Yin Y, Giang G, et al. Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. J Occup Env Med 2000;xxx.xxx.

3. "Exercise Before Surgery Aids Recovery,’ Reuters, September 17, 2002

4. "Health Promotion/Managed Health Provided by Major US Employers in 2001"; "Health Expectations: Future Strategy and Direction," Hewitt Associates, 2002.

5. Swedlow A, Johnson G, Smithline N, Milstein A: Increased costs and rates in the California Workers’ Compensation System as a result of self-referral by physicians. N Engl J Med 1992; 327:1502-1506.

6. Mitchell JM, Scott E: Physician ownership of physical therapy services: Effects on charges, utilization, profits, and service characteristics. JAMA 1992;268:2055-2069.

Michael Weinper, MPH, PT, is President, CEO and founder of PTPN, the nation’s first and largest network of private rehabilitation practitioners, headquartered in Calabasas, CA  
(www.ptpn.com). He can be reached at mweinper@ptpn.com or 818-737-0215.

The 15 Most Costly Medical Conditions

Source: Cohen JW, Krauss NA: Spending and service use among people with the fifteen most costly medical conditions, 1997. Health Affairs 2003;22(2):129-138. Data are from the US Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997.

HOW REHAB HELPS

Rehabilitation plays a crucial role in the treatment and management of many of the costliest medical conditions.

• Heart disease. Heart attack survivors are at increased risk for recurrent heart attacks, cardiovascular complications, and sudden cardiac death, but those who participate in cardiac rehabilitation have improved survival rates.* Cardiac rehabilitation helps heart attack survivors rebuild their cardiovascular condition with an aerobic regimen to encourage the arteries to become more elastic and expand easily. Exercise helps the body to develop new pathways of blood supply, and retrains blood vessels to and from the heart.
• Cancer. Cancer patients are often left debilitated and possibly disabled after cancer treatments. Physical therapists work with patients to decrease fatigue, nausea, and pain and to improve strength, endurance, general mobility and quality of life. They help patients learn how to relax, conserve energy, and manage stress.

Breast cancer survivors with lymphedema—swelling of the arm or hand that occurs after removal of lymph nodes under the arm–may go to lymphedema-certified therapists who use noninvasive techniques to reduce the swelling.

Men who have had prostate cancer may suffer from urinary incontinence. In many cases, physical therapy involving biofeedback as an adjunct to exercise will help.

• Trauma. The two most severe disabling injury conditions are traumatic brain injuries and spinal cord injuries. Patients may require long-term physical and occupational therapy to help restore functional mobility and independence. Some patients may need speech-language pathologists for treatment of voice and articulation disorders and language problems, including speaking, understanding, reading, and writing.

• Mental disorders. Physical therapists who specialize in fitness and who use yoga, Pilates, and Tai Chi in their practices say their patients experience—along with increased strength and flexibility–a better overall feeling of well being. Those suffering from depression, anxiety, and stress find their symptoms improve with physical activity because serotonin levels increase through exercise.
• Pulmonary conditions. Patients with emphysema or chronic obstructive pulmonary disease, or those who have inhaled asbestos or other pollutants that cause restricted breathing, gain strength through the use of breathing re-training techniques. Although a pulmonary rehabilitation program may not be able to increase lung function in all patients, it can help make muscles more efficient so patients can do more with the lung capacity they have.
• Diabetes. Physical therapists prescribe exercise programs to help patients control their blood sugar. Physical activity helps lower blood glucose concentrations, reduces the dose of oral diabetes medications, and increases insulin sensitivity. People with diabetes who exercise require less insulin and have better outcomes than those who are sedentary.
• Stroke-related conditions. Stroke patients show improved recovery with early intervention by physical, occupational, and speech therapists as part of a critical stroke team. Physical therapists are now using neural retraining techniques to help the brain reorganize itself around damaged areas to deal with sensory input.  Another technique— constraint-induced movement therapy — temporarily restricts movement of a patient’s working limbs to encourage use of the affected limbs.
• Osteoarthritis. Arthritic conditions including osteoarthritis are the leading cause of disability in the U.S. and a major financial drain on our health care system. Physical therapists treat arthritic patients with a variety of techniques and modalities, such as aerobic exercise and weight resistance in a warm pool. Recent research shows that strength training not only reduces the pain and stiffness of arthritis, it also slows the progression of the condition–and, in some cases, reverses its effects.
• Back problems. Back pain is the most common cause of loss of activity among adults over 45, and half of all American workers will suffer back pain at some time during their careers, according to the American Physical Therapy Association. Physical therapists design individual treatment regimens aimed at restoring flexibility and easing discomfort. Treatment may include heat, cold, massage, traction, manipulation, and exercises for relaxation, conditioning, and improving range of motion. Several forms of electrical stimulation are used to control acute back pain and muscle spasms. New modalities including lasers are showing promise in the treatment of these conditions.

*Receipt of cardiac rehabilitation services among heart attack survivors–19 states and the District of Columbia, 2001. MMWR 2003;52(44):1072.

Michael Weinper. Managing the Most Costly Medical Conditions.

Business and Health

August 2004;22.