Winter 2019/2020

Rehabilitating Your Rehab Program

Fast Focus

Physical medicine programs often focus on simple metrics like number of visits and price per service, lacking serious clinical insight into the effectiveness of care. Embracing a more dynamic system of clinical metrics provides a clearer understanding of program performance to drive educated care decisions that improve claims outcomes.

Injured worker care requires a variety of components, and beyond prescription medications and medical devices, patients may benefit from physical medicine services to help rehabilitate their injured bodies.

Physical medicine services already make up 13% of medical costs in workers’ comp claims,1 and as providers shift away from opioids, they have begun to embrace more physical medicine treatments,2 meaning that future claims could see more utilization.

But just like managing pharmacy benefits, physical medicine programs require strong oversight to ensure patients receive services that are appropriate for their condition, are cost effective, and result in clinical improvements over time.

With this in mind, what should payers know about optimizing physical medicine programs?

Physical medicine services make up 13% of medical costs in workers’ comp claims1 and are expected to rise


Physical medicine is a branch of medicine that focuses on restoring functional ability to patients facing physical impairments, which may result from workplace injury, primarily through active physical exercises or manipulation.

Physical medicine services in workers’ comp typically include physical therapy, occupational therapy, and work hardening and work conditioning. See below for an analysis of physical medicine according to Healthesystems data.


Physical Therapy
Occupational Therapy
Work Hardening and Work Conditioning
Other physical medicine services can also include:
Massage therapy
Aquatic therapy
Functional capacity evaluation


When utilizing physical medicine to treat a workplace injury, active modalities that embrace strengthening exercises or direct manipulation are preferred over passive modalities that simply target pain or swelling.

It is for this reason that a strong physical medicine program should embrace the industrial athlete model. Borrowing from sports medicine, the focus of care is less about managing pain and more about immediately rehabilitating the root cause of injury to help patients to function again.

An athlete does not simply walk onto a field and play. Over time, they train key parts of their body with specific exercises that help them better perform. When properly integrated into physical medicine programs, the industrial athlete model can help injured workers strengthen their bodies over time, focusing on the specific demands of their occupation.


Embracing evidence-based physical medicine at an early and appropriate stage can result in:

59% decrease in the number of physical medicine visits when compared to care not adherent to treatment guidelines4
50% reduction in disability scores and mean time off from work5
28% decrease in prescription costs compared to care not adherent to treatment guidelines4
10% reduction in long-term opioid use6
More consistent and significantly lower-dose opioid use claims7

However, physical medicine must be properly managed in order to reap these benefits. When comparing physical therapy outcomes in low‐back pain patients, a stark difference was found between care adherent to treatment guidelines against non‐adherent care. Nonadherence more than doubled physical therapy utilization, while prescription costs increased nearly 40%.4

Furthermore, the Journal of Occupational and Environmental Medicine found that claims with 15 or more physical therapy visits were six times more likely to result in higher costs and four times more likely to last longer than typical claims.8 While this data could be tied to severe claims that require a significant amount of care, it could also point to the ineffective delivery of physical medicine, rife with potential overutilization.

Therefore, it is crucial that physical medicine programs find the proper balance of ensuring patients adhere to therapy, but also monitoring patient progress to ensure that physical medicine isn’t being overutilized with ineffective care.


Many programs focus solely on monitoring the number of service visits a patient undergoes and the price per service. Instead of focusing on the effectiveness of the services provided, this model adheres to preset utilization averages, delivering little insight into patient progress, especially since the disparity of injury severity and care needs vary so greatly in claimant populations.

For physical medicine programs to be successful, they must be driven by evidence‐based medicine that ensures scheduled care visits are clinically appropriate and likely to benefit a patient’s specific condition, and backed by metrics that determine if care interventions are resulting in functional improvement, both of which are lacking in many programs.

Lacking transparency into the effectiveness of care can result in longer claims, dissatisfied patients, and higher costs. Furthermore, patients lose out on meaningful care opportunities that could greatly benefit them.


First and foremost, physical medicine programs must be built around evidence‐based medicine to ensure that prescribed treatment interventions are clinically appropriate for a patient’s injury. Inappropriate care does little to help the patient and merely increases claim costs.

Second, physical medicine programs must gather various advanced metrics to better judge the impact of care, as well as optimize care delivery.



By capturing patient‐specific measurements, physical medicine programs can establish a baseline of patient function that can be monitored and evaluated over time to determine if services are effective. This can include:

Range of motion



Quality of life

Clinical metrics can also include provider‐specific measurements that document the quality of care delivered, including:

Number of modalities performed per visit

Average number of visits per week

What type of services are performed in each visit, such as physical therapy or occupational therapy

Time spent with patients per visit

The mix of active versus passive modalities

By analyzing patient data alongside provider data, the true value of care provided over time becomes more transparent, allowing stakeholders to make informed care decisions, both on a claim level and on a program level.


While it is important to capture provider metrics, it is also important to capture metrics related to the vendor networks that those providers fall under. It is crucial that claims professionals understand how well their vendor network partners handle day‐to‐day administrative duties that connect patients to providers and support a physical medicine program. Strong workflows and program designs are only useful when supported by exceptional vendor performance and follow through.

By quantifying vendor network performance, stakeholders can better compare different vendors and make care decisions that better serve the patient and reduce costs, while also incentivizing underperforming vendors to improve.

Operational and service metrics can include:

How quickly service providers within a vendor network conduct an injured worker’s initial evaluation after an initial request for service (RFS)

The percent of time vendor network providers capture key clinical measures like range of motion

How effectively vendors handle requests for service

How efficiently vendors schedule initial appointments

How timely and correctly vendors and providers bill for services

Peer reviews of treatment requests


Like any managed care program, physical medicine programs benefit greatly from the collection of granular utilization metrics, giving payers the ability to understand treatment patterns, identify and better manage unique populations, target more severe claims, and find opportunities to reduce unnecessary spending.

Utilization metrics that can benefit a physical medicine program include:

Number of physical medicine visits per claim, as too few or too many could point to overutilization, either from lack of necessity or lack of impact

How many services are delivered per visit, as greater intensity of care can benefit patients when services are clinically beneficial, but simply inflate costs if not

Number of visits per week to gauge the frequency of care and understand if care is provided regularly enough to have an impact

The ratio of active modalities to passive modalities to ascertain the likelihood of clinical impact, as passive modalities are only beneficial in acute stages of recovery

Length of treatment by injury type and body part, helping to stratify claims and determine trends in care, outcomes, and spend


By integrating more data collection into physical medicine programs, payers gain greater transparency into care outcomes. This allows payers to drive better care decisions for better outcomes, resulting in reductions in:

Fraud, waste, and abuse

Excessive or ineffective service visits

The need for prescription medications, including opioids

Costly surgery, advanced imaging, and therapeutic injections


For a physical medicine program to effectively intake and manage so much data, technology must be properly utilized to allow for various interfaces with different physical medicine vendors.

Furthermore, partnerships with vendor networks must be formed with well‐constructed service‐level agreements and superior workflows to ensure the program is efficiently managed.

Healthesystems’ unique physical medicine program accomplishes this, allowing payers to more effectively manage the quality and utilization of physical medicine services in workers’ comp claims. By applying objective clinical measures to accurately assess treatment efficacy and vendor performance, we enable our clients to better serve patients and lower spending.


One example of how Healthesystems monitors vendor performance is by conducting billing audits on the “8‐minute” rule. Many physical therapy interventions are billed in 15‐minute increments, and in order for providers to bill for one of these increments they must be directly engaged with the patient for a minimum of 8 minutes.

After implementing our audit analytics model over a nine-month period, the percent of bills that did not pass an 8‐minute audit fell 30%,3 indicating that the tool has driven improved vendor performance.


  1. Lipton B, Robertson J, Corro D. Medical services for claims 20 or more years old. NCCI. Jan 2013.
  2. Research spotlight: non-pharmacologic services for pain management in workers’ compensation. WCRI. Sept 24, 2019.
  3. Healthesystems data.
  4. Childs JD, Fritz JM, Wu SS, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research. 150(2015).
  5. Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12:102-11.
  6. Sun E, Moshfegh J, Rishel CA, et al. Association of early physical therapy with long-term opioid use among opioid-naïve patients with musculoskeletal pain. JAMA Netw Open. 2018;1(8):e185909. doi:10.1001/jamanetworkopen.2018.5909.
  7. Zhang J, Yu Y. Early indicators of high-risk opioid use and potential alternative treatments. WCIRB. April 2019.
  8. Leung N, Tao X, Bernacki E. The relationship of the amount of physical therapy to time lost from work and costs in the workers’ compensation system. Journal of Occupational and Environmental Medicine. August 2019. 61(8):635–640. doi: 10.1097/JOM.0000000000001630 -


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.