Part 1: Payment Paradox

Following on from last month’s blog on the pathologising and monetisation of pain, I’m delving further into the capitalist machine of health and welfare. The public-private practice divide in physiotherapy encapsulates other issues surrounding access to healthcare and the social constructs around this. But we’re staying fairly microscopic with this post, don’t worry. This will also be delivered in two parts, as it blew out a touch.. Who knew these topics were so involved.

After graduating I was certain I needed more experience in every aspect of physiotherapy and began cutting my teeth in the public sector outpatient departments and orthopaedic wards. I have since worked privately in a typical musculoskeletal clinic, I have run my own business and now I am fortunate enough to be in a third party payment position. So having been to both corners I feel I am in some position to ask important questions.

So that’s what I’m doing; you will hear from both the public side and the private side in a debate about the value of payment in physiotherapy (and hopefully this extends to other health areas in time).

Why paradox?

   “I will take your money and provide the advice that you need to stop giving me your money”

A refreshing push toward using the simple things well is becoming apparent in physiotherapy literature and popular media. I have felt hamstrung by the payment paradox through various stages of my career. The best practitioners I know are excellent diagnosticians capable of determining the root cause of musculoskeletal disorders. They will provide appropriate advice to create empowered, active copers through behaviour change; essentially ensuring patients do not come back. Are we, as physiotherapists, doing ourselves out of a job? In ensuring your business thrives, the ‘ethos’ of physiotherapy (in my opinion) seems muddied. Does payment simply propagate the system and cycle of ongoing dependency?

I asked the following three questions to the most esteemed public and private practitioners that I am aware of in my immediate vicinity; if you need to know more about these legends, please click on the links to their Linkedin profiles. Chris Barnett and Steve McCullagh.

–  Do you think, as a public/private service, a patient not paying/paying for your time has an impact on YOUR service as a practitioner? Explain your response. – Do you think, as a public/private service, patients not paying/paying for your time has an impact on the outcomes of your service? – If so (above), why? If not (above), why not? CB: For me the question is about behaviour change and does a fee paying structure change the behaviour and hence the outcome?

Some private health insurance companies in the (United) States take the opposite approach and pay their members for healthy behaviours and ultimately outcomes. For example $500 for 10% weight loss and $500 bonus for keeping it off for 1 year. Charging people to get healthy is a bit like a gymnasium model; everyone starts off paying their monthly premium but then soon drops out. Receiving a service for free, such as a public physiotherapy could actually be an issue of equity. Social determinants of health tell us that the people who can least afford high quality nutritious food and, gym memberships  have the poorest health outcomes. Charging this community will not, in my opinion, lead to better outcomes but price them out of the market. However, that’s not to say that the relatively wealthy middle classes (the worried well) would do better with a payment structure that equated to a commitment and behaviour change.

So it’s a question of value, and for me public patients are still ‘paying’ with their relatively exorbitant car park fees, their bus tickets, their time to get child care, and  will only attend if they value the service that is being offered. That’s a service that respectful of their rights, non-judgmental, truly patient-centred and collaborative.

There have been attempts to charge people for non-attendance in public sector, I’m not sure of the outcomes of these ventures, but think SMS reminders and other avenues such as Telehealth that are built around the patient are good options.


SM: Do you think, as a private service, a patient paying for your time has an impact on YOUR service as a practitioner? Explain your response.

When a patient pays; their expectations for the services are stronger, and need to be addressed more, than a patient who is not paying for the service. For me personally, there is very little difference between the actual services provided. When a patient is paying, I will be more attentive to their expectations (due to the strength of these), but I will invariably be attempting to lead them down the same journey as the patient who is not paying.

Do you think, as a private service, patients paying for your time have an impact on the outcomes of your service?

I find the challenge with paying patients is educating and getting to the bottom of what a truly successful outcome is. Education that just the absence of pain, is not a true success and is likely, temporary. The underlying activities, pathology, strength or conditioning has not been adequately addressed. Often patients who are paying, will ‘self discharge’ in the absence of pain, as their ingrained expectation is no pain = job done.

When a patient is not paying, they are generally more open to continuing beyond this asymptomatic period; to a baseline and performance phase of their rehabilitation and long term outcomes.

This ‘self discharging’ needs to be addressed at the outset. This involves clear explanation of what the pathology is, how the recovery will track, the patients expectations and focusing not on pain and disability, but what the patients real success and goals are, in the medium to long term. If you can achieve these outcomes in a timely and cost effective manner, patients will love you for it! If they need to keep returning for flare ups, re-injury, failure or similar injuries, they wont be singing your praises for long.

So what?

There is a common theme; both practitioners make it clear to be successful you need to be attentive to patient values and collaborate toward a combined goal. I think it truly does come down to a question of value. What does the patient in front of you value? Social constructs may dictate how your patient will value being free of pain versus enhanced function and quality of life; I would hazard a guess that only in some specific circumstances do these values align with your own as a practitioner. I have been to both sides of the divide and in my view the only things you are really trying to create in individual patients is behaviour change; again both practitioners above champion this with their own language.

In my view, I don’t think physiotherapy has quite the staying power when combating other more powerful social constructs (education, lifestyle habits, and socioeconomic status) in the public environment. I know I would rather put a roof over my babies’ head over buying a gym membership; I think presuming the success of outpatient physiotherapy in a public environment is looking through some slightly rose-tinted glasses. Heck, the buy-in for improved health and function has already occurred when someone has paid for the service. In a private environment, however, I think the monetisation of pain leads to a muddied message from even the best practitioners. I know myself I found it difficult to give a guilt-free message of empowerment and self-reliance. But I think the future of physiotherapy certainly lies more with the private enterprises; what they will look like in years to come is another thing altogether.

End of part 1.

Just like this post, this song delivers so much and then ends halfway through… leaving you wanting and a little empty inside. But it rocks and you should listen to it. Then have some chocolate to ease the pain of humanity going to shit.

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