Good Thing Bill’s No Average Joe

WASHINGTON — If President Clinton were just ordinary Bill Clinton, he probably would be facing a personal health care dilemma just about now.

It has been almost 60 days since he ripped the quadriceps in his right knee, and that’s when most insurance rehabilitation coverage would end--if it hadn’t elapsed already.

Physical therapy, like mental health treatment and occupational therapy, is an area of health care where there has been spirited debate over how much treatment is enough, especially during the recent years of cost-cutting fervor.

Clinton, whose injury can require up to six months of rehab, would probably be faced with deciding whether to pay on his own for more services or to fight his insurance company to get more coverage. Typically, he might decide to start learning how to perform exercises at home, on his own, at no cost.

Because he is president, however, a physical therapist comes to the White House and supervises Clinton through two 45-minute sessions every day.

To be sure, nobody suggests that the president does not deserve the gold standard in health care. But in this era of managed care, Clinton’s treatment underscores the gulf between what that gold standard is and what most people actually get.

“My insurance authorized a total of nine visits,” said American University history professor Ira Klein, who slipped down a muddy hill near the AU campus in December and suffered an almost identical injury as Clinton, although not as severe.

To make his 40-minute rehab sessions last over a longer period, Klein spread them out to one every week to 10 days. “They told me people get better faster if you come in twice a week, but I didn’t want to exhaust the treatments,” Klein said. He has access to the AU gym and now uses the equipment there to do therapy on his own.

Studies show that every dollar spent on rehabilitation saves $30 in long-term disability costs, according to the American Rehabilitation Assn. Yet the average American is allowed 60 days for treatment under the typical managed care plan, the group said.

Kathleen Yosko, who chairs the association, said “thousands of Americans are denied access” to rehabilitation and other specialty services because of strict referral rules governing physicians in managed care plans.

Typically, the most limited coverage occurs with health maintenance organizations.

“From what I’ve seen, most plans will cover some medically necessary rehabilitation,” said Cara Jareb, a consulting actuary with Watson Wyatt Worldwide, an international management consulting firm that works with employers in drafting health plans for their companies.

“But there aren’t unlimited resources,” she added. “Most employers have provisions for physical therapy, but there are visit limitations.”

Some plans are more generous than others. For example, Blue Cross / Blue Shield National Federal Employees health benefits program, which covers millions of government workers, provides 50 physical therapy visits a year under its “standard” option plan and 75 under its “high” option program, Jareb said.

Perry Esterson, spokesman for the American Physical Therapy Assn. and a physical therapist in private practice, said most of his patients get seven or eight visits under their plans before they begin home-based regimens. These home exercise programs work only if patients are instructed well and are rigorous about sticking to them.

In California, “many managed care settings authorize only three visits, which is ridiculous,” Esterson said. “Even if you have the most motivated, educated and compliant patient” willing to adhere to a home program, three outpatient visits with a professional “is not enough,” he said.

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John Brickley, executive director of the outpatient network at the National Rehabilitation Hospital in Washington, agreed.

“We have to build the best models of care for the best outcomes at a reasonable cost,” he said. “What the insurers have done is place arbitrary restrictions on us that are simply to reduce the costs. They don’t take into account the different needs of different patients.”

He favors “capitation” policies, in which health providers receive a certain amount of money per member per month, regardless of the care they deliver. The providers then decide how to portion out therapy.

“At least this puts more control in the hands of the provider,” Brickley said. “You have to budget how you deal with that amount of money. It’s not the best, but it’s a lot better than arbitrary decisions that don’t take individual patients into account.”

The president, by law, receives his health care under a military plan, said Mary Ellen Glynn, a White House spokeswoman.

This is why most of his surgery and most of his treatment was performed by military physicians.

Clinton also has a private health insurance policy, mainly for daughter Chelsea. This plan did cover his emergency care in a Florida hospital on the night he was hurt, Glynn said.

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Clinton’s recovery is progressing ahead of schedule. “He’s been very cheerful about everything,” Glynn said. “He’s even lost 5 pounds.”

Clinton has already gained 90-degree mobility in his injured knee, which experts say is critical for such tasks as going up and down stairs and getting in and out of cars. It takes most people four to eight weeks after starting rehab to achieve 90-degree mobility, Esterson said. Clinton reached that goal some weeks ago, Glynn said.

When Clinton boarded Air Force One en route to Mexico on Monday, his physical therapist was there too.

While such a luxury is denied most Americans, “In the old days we would have gotten pretty much whatever we wanted in the way of therapy,” Brickley said. “Certainly, there was not enough focus then on reducing costs. But now, it’s shifted too far the other way.”