Saturday, January 16, 2010

Insurance-Defying Fitness: In Praise of Marilyn Moffat

Gina Kolata’s recent article, “Treat Me, but No Tricks Please,” in the New York Times, brought on a firestorm in response.  In the article, Kolata questioned whether there was “rigorous evidence” to show that physical therapy was effective and asked, “With all that voodoo physical therapy out there, though, how can you tell if what you are getting is helping or useless?”

There was much to criticize in her analysis, and the criticism came on fast:  Within a twenty-four hour period, the article garnered more than 180 comments online, so many that the Times closed the article to further comments.  Even her own physician, whom she quoted in the article, felt compelled to respond:  “Physical therapists are uniquely trained to restore function, improve mobility, relieve pain and prevent or limit reinjury.”  

Many commenting offered persuasive arguments to contradict Kolata’s view, and I won’t add to that.  There is one statement Kolata made, however, about which not much was said:  “. . . my health insurance companies have always covered physical therapy for sports injuries.   Their willingness to do so is not necessarily an indication that the therapy is effective.”

On that point, I agree.  Insurance company protocols for covering physical therapy are often perverse, tending to lavish payments on multiple visits for ineffective treatments and refusing to cover limited visits, spread over time, for treatments that actually work. 

When I opened my practice ten years ago, I experienced repeated repetitive stress injuries arising from increased time at the computer.  For each injury, I was prescribed physical therapy.  The regimens involved lots of equipment and multiple visits per week for several months (downtime I could ill afford)—all covered by insurance.  The treatment was focused primarily on the specific problem.  Time would pass, and I would get another injury.

I tried several different physical therapists, each time with the same result.  For the most part, they were good clinicians with sensible things to say, but something was missing.  I came to realize that, to maintain financial viability, insurance requirements, not treatment needs, were the primary drivers of their approach.

In despair of finding a better solution, I consulted a colleague who recommended Dr. Marilyn Moffat, a pre-eminent professor of physical therapy at New York University.  (Dr. Moffat is the co-author of, among many other books, the wonderful “Age-Defying Fitness.”)  Dr. Moffat assessed my injury history and set up a regimen I could do at home.  The regimen involves no equipment other than a mat, a chair, a Theraband, and some weights.  Our sessions quickly moved from once a week to once every three or four months

In the visits, Dr. Moffat assesses my progress and adjusts for any issues that may be present.  Under her care, I have not had a single repetitive stress injury for many years—and the benefits, as I age, go far beyond that.  I could not have accomplished this on my own.

Though Dr. Moffat has prevented injuries that previously cost the insurer thousands of dollars in claims it willingly paid, my claims for visits to her, costing a modest amount per year, are routinely returned with requests for extensive documentation to demonstrate medical necessity.  I tried once to meet the requirements, but, despite time-devouring efforts, the claim was denied.

I’m lucky enough, at present, to be able to pay out of pocket, so I’ve not tried again.  But that’s no solution to the problem:  it’s just a dodge I’m able to make that no one should have to—and not everyone can.

My story isn’t unique:  I believe it to be the norm.  We need a wholesale overhaul of insurance coverage for physical therapy, and particularly geriatric use of physical therapy, to promote ongoing wellness and aid in preventing injury as we age.  Insurance companies should not only cover, but give incentives to patients and therapists to promote Dr. Moffat’s approach, particularly for the geriatric population.  If everyone over 60 were under the guidance of a physical therapist using Dr. Moffat’s techniques, the cost savings to the health care system would be immense.

I'm just saying . . .


  1. Ever the fitness cat, Nesreen awaits her turn with the Theraband. Her Human and her Human's Mom loudly applaud Dr. Moffat's most welcome and necessary system of PT for oldsters. I'd go on but must leave now to pick up a new orange Theraband to replace the one I've worn out!

  2. I do agree. The way physical therapists are reimbursed and are forced to function is defenitely responsible for much less than optimal clinical patterns. Only true direct access to physical therapy, banning physicians from owning PT practices and changing insurance reimbursement pathways will result in meaningful change and will help to position this profession where it needs to be.

  3. You are very correct that insurance reimbursement needs to change. The problem is that physical therapy in the eyes of insurers is just the same as in the eyes of many people, neither really knows what we do. The profession needs to better market ourselves to patients and insurance companies alike. Take for example the Virgina Mason Medical Center useing the Toyota Model. This is an area where policy was changed and caused a huge reduction in cost to insurance companies and employers.

  4. The health insurance industry seems to run counter to the conventional wisdom in medicine that it is better to prevent something than to treat it later. As Michael Pollan says "Better to pay the grocer now, than the doctor later."

    Unfortunately most health insurers, and most Americans, seem to want to just take a pill for what ails them, instead of trying to live healthier in the first place.

    Good luck with your preventative efforts!

  5. To Adam and the anonymous commenter: thank you so much for writing and offering your interesting perspectives on the issue.

    And, Wide Open Spaces: thanks, as always, for your comment, including the great Michael Pollan quote.

  6. Here in we are all assailed by the government and health authorities to take more responsibility for our health and rightly so-better school diners, give up smoking, poor nutrition, less booze and even forget the gym and get walking-even take therapy (quick and cheap course naturally). Whilst this is a very welcome change from instant pills, and surgery, sadly it still reflects the Western economic obsession with work and making money (for some) rather than human kindness and community benefit.Given that we can only try as best we may for our own objectives.Getting good advice is important because ill-informed physical therapies or exercise can cause damage too.I tried power-walking this weekend, as advised by the Guardian newspaper supplement, and my ruptured disc did not appreciate it at all.I wish you luck with your campaign and meanwhile applaude the excellent results you have achieved by your determination and effort to get yourself fit.In the end, we all have to try so I best get off this pc.....!

  7. There really SHOULD be a UKGymandchips website! And, ah, yes--getting off the pc, now there's the rub!

  8. The pharmaceutical industry, with its huge lobbying clout & pockets fathoms deep, does not want preventive therapy for the most obvious & American of reasons.

  9. Yes, funny thing that. You don't see staplers and notepads in MD offices that say, "Exercise," or "Eat Right," now do you?

  10. Raining Acorns - your last comment reminded me of something I read in a book a few years back. A doctor tells his patient he has a pill that will prevent heart attacks, keep him flexible, and prevent many other maladies. The man says, great -give me a bottle of it. The bottle's label says, "Take 1 pill daily after 1 hour of exercise."


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