UPMC network's steps irk private physical therapists

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Gregory Waite has run his physical therapy private practice in Waterford, Erie County, for 10 years.

Waterford Physical Therapy and Sports Rehab has had a steady business of people seeking help to recover from injury and illness. It even got a boost a few years ago when it became a designated provider for UPMC Health Plan patients.

Now Mr. Waite is wondering how many of those patients will stay with him.

A few months ago, Mr. Waite -- who is also president of the 3,500-member Pennsylvania Physical Therapists Association -- learned that UPMC Health Plan had designated Waterford a "Level 2" provider for some of its plans, which means higher costs for his patients. Under these plans, he said, only UPMC-owned physical therapy practices are "Level 1" and will cost patients less.

For example: A patient seeking treatment at a Level 1 provider may face a $30 copayment each visit, or $600 if they have 20 visits per year. Under Level 2, a patient may pay about $100 per visit until they met their yearly deductible -- typically $750 or so -- after which they would pay $20 to $25 per visit.

Steering patients to its own physical therapists "makes good business sense on [UPMC's] part," Mr. Waite allowed, "but, at the same time, you have to look at whether the patient is being provided that choice."

He added that some studies have found that in self-referral situations, "the services are used twice as often and the length of stay is 2½ times longer."

Closer to home, independent physical therapists in Pittsburgh worry that Erie, with its two major hospitals now part of either UPMC or Highmark's Allegheny Health Network, may be a harbinger of what's to come.

Local physical therapists "are very concerned about where this fight [between Highmark and UPMC] is going to lead," said attorney J. Kent Culley of the Downtown firm Tucker Arensberg, which represents more than a dozen Pittsburgh-area independent physical therapy practices.

Network access for local physical therapists has been a mixed bag.

While Highmark has been open to nearly all licensed physical therapists, access to UPMC's network has been more limited. Paul Rockar Jr., CEO of UPMC Centers for Rehab Services, has said the network is deliberately narrow "to ensure the kind of standardization and oversight needed to achieve its patient-focused outcomes."

As Highmark's Allegheny Health Network gains its footing, the concern for local independent physical therapists is that Highmark may take a similar approach and steer more patients to AHN-affiliated practices.

"Inquiries have been made to Highmark about status and what's happening with their providers, but there's been nothing definitive coming back the other way," Mr. Culley said.

Highmark says local therapists need not worry.

"We have no plans to limit physical therapists in any way," spokesman Aaron Billger said, "and frankly we expect to see an increase in patient services in the future and a great need for independent physical therapists."

Fear of being excluded from emerging integrated delivery systems also is a concern nationally for independent physical therapists, said Justin Moore, vice president for public policy, practice and professional affairs for the American Physical Therapy Association in Alexandria, Va. "The concern is that this is going to get tighter and more restrictive going forward."

Independent physical therapy practices do have a couple of options, he said: Demonstrate through hard data that they can provide high-quality care more efficiently or, if the network says it has no need for additional practices, join forces with other independents.

"There are also a lot of small, independent practices in high quality niches, which are experts in women's health or cancer rehab," he said.

One argument for keeping services such as physical therapy in-house is that the health system can maintain better quality controls and better coordinate the patient's ongoing care.

Mr. Waite thinks there's more to consider, though.

"Every person I've treated, I know," he said. "If you go to one of those facilities, they may know who you are or they may not. You're not going to get that personal service."

Steve Twedt: stwedt@post-gazette.com or 412-263-1963.

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