NEW YORK, NY February 09, 2005 —More and more Americans are seeing physical therapists to help repair their ailing and injured muscles, bones, joints and ligaments. But the definition of what is “cured” is not always clear – and for thousands of New Yorkers, it may be changing. WNYC’s Fred Mogul has this report.

FM: Jianna Ruggiero is one very small physical therapy patient. The toddler doesn’t have a bad knee. For the first year of her life, she had tight joints throughout her body. Her mother Jaime says her daughter’s elbows were constantly clenched close to her shoulders.

JR: They think in utero she wasn’t moving and that’s what caused – it’s called artho-griposis. She has a mild case of it, but she has it in her arms, and she’s made so much progress with therapy.

FM: Jianna is being stretched and pushed and twisted – today in the clinic, and every day at home. Her physical therapist, Joanne Ferrara, says thanks to this regimen, Jianna now can flex her elbows about 140 degrees.

JF: Normal is 180 degrees of straight, which would be perfectly straight. She obviously is not 180 degrees. She certainly is on her way…but she is not there yet.

FM: Jianna was denied further coverage after 22 visits. Her parents thought their policy allowed 30. The denial said Jianna met the “discharge criteria” for elbow flexion. Ferrara says it’s significant that Jianna was rejected when her range of motion reached 140 degrees. That’s about 80 percent of 180 degrees. She and other physical therapists say they see that percentage come up again and again with a company called OrthoNet. White Plains-based OrthoNet handles physical therapy, the same way other firms manage drug, dental, or visual benefits. And it could affect you -- because OrthoNet now is the gate-keeper for three of the region’s largest HMO’s – Oxford, Empire Blue Cross Blue Shield and Cigna. Jim Nugent, from the American Physical Therapy Association, says he probably gets five complaints about OrthoNet for every one he gets about all the rest of the country’s benefits-managers. And one of the main grievances Nugent hears is that OrthoNet cuts patients off when they’re “80-percent-cured.”

JN: You would think you would want someone to return to the function that they had before their injury. If they’re lifting boxes, and their job calls for them to lift 50-pound boxes, to go back and say, ‘You can lift 40 pounds, that’s okay.’ A person can’t go back to work, they can’t do their job. But they’re at 80 percent of 50, so what the heck.

FM: OrthoNet initially declined to be interviewed. Its Medical Director, Dr. Robert Refowitz, dismissed the 80-percent figure as something made up by physical therapists. Then, WNYC obtained OrthoNet documents clearly confirming the company does use 80-percent. The documents are called “Discharge Criteria.” Each one covers a different condition: Torn Rotator Cuff. Knee strain. Bunion. And for all of them, it clearly states at the top: “OrthoNet’s discharge criteria for range of motion, strength and function are defined as 80-percent of established normal values.” The number comes up repeatedly. Confronted with its own documents, OrthoNet agreed to speak. Dr. Robert Refowitz.:

RR: I can see how you might incorrectly draw that conclusion, but based on where it is actually used, it’s totally appropriate in every case – range of motion, strength – it’s appropriate.

FM: As an example, Refowitz opened a book called “Clinical Orthopaedic Rehabilitation” and read the description for repairing the knee’s Anterior Cruciate Ligament, or ACL.

RR: They’re describing ACL construction care, and they’re talking about comparing one side against the other, and it says, “[if] the test of hamstring strength is 85% or better, discontinue iso-kinetic hamstring workouts.”…These are standard measurements.

GL: They’ve mis-applied that particular guideline…

FM: Gaetano Lombardo teaches at NYU and has written managed care guidelines for physical therapy. He opened the same book and found several cases telling therapists to discharge patients when they reach 100-percent strength and range of motion.

GL: Certainly the knee ligament problems – those are specific to sport populations, athletes. To take that and apply that to an individual who might be in their 50’s is just inappropriate…They’re taking some guidelines that are meant to be very narrowly applied, with respect to diagnosis and patient population, and they’re generalizing them across diagnoses, across body parts and across populations.

FM: OrthoNet says it tailors all decisions to individual patients. Refowitz emphasizes that whatever scores patients receive for strength, pain and range of motion…what really counts is what they can do – whether that’s bend over to tie their laces or reach in their back pocket to get their wallet.

RR: The goal is to get folks using short-term restorative therapy to take them back to their basic activities of daily living – that’s not marathon running, that’s not competitive skiing, that’s not competitive tennis.

FM: That’s also not informal recreation – and, according to the documents WNYC obtained, not even, quote, "return to specific vocational and/or occupational activities." In other words, you can not expect therapy to get you well enough to work again. Physical therapists say OrthoNet is more restrictive than any other major company -- and this ‘basic-life-function’ standard – whether or not it’s actually “80-percent” – is a radical paradigm shift. Again, Gaetano Lombardo

GL: If someone is 40 years old and they hurt their shoulder, and they want to become a pitcher for the New York Yankees, most insurance companies are probably not going to support that. But if the individual is the coach of his son’s little league team and he needs to be able to throw batting practice, and he had been doing that prior to the development of his shoulder injury, other case-managers will allow that individual to continue treatment… assuming they make reasonable progress toward that goal.

FM: But not with OrthoNet. Refowitz says the company is upfront to therapists about how it defines wellness, and that it’s the primary insurer’s job to set policy and inform patients. But both patients and therapists say it’s nearly impossible to get this information. If you have Oxford, Cigna or Empire Blue Cross, you will not find it in your Benefits Book or on the Help Line. To be fair, it’s difficult to get much information from insurers about the details of policies, especially when it comes to definitions and exclusions. Even the employers who buy policies and the brokers who sell them rarely, if ever, know all the fine points – even when the contracts are worth millions of dollars. We called Customer Assistance operators at several of the region’s largest HMO’s. None of them could clarify where their plans draw the line for physical therapy coverage. They all said such information is part of the “medical review process” – a process that occurs after you start treatment, not before. Joe Baker, Attorney General Eliot Spitzer’s chief healthcare enforcer, says you have a right to that information.

JB: Under the state law, they are required to give this to a consumer, if the consumer asks for it in writing – as a way for the consumer to shop for healthcare…The other place they may need it is once they are enrolled in a plan and they are denied care.

FM: Baker’s office found that most New York HMO’s frequently violate this law. Spitzer has sued them and is working out a settlement. But there are exclusions, and there are exclusions. Insurers are not required to list all details in advance, only to provide them upon request. Other sweeping exclusions are so broad they must be listed openly, like “No cosmetic surgery” or “No visual care.” Baker says OrthoNet’s exclusion of “return to sport, recreational or vocational activities” probably meets this standard.

JB: If an exclusion is across-the-board, ‘you’re-never-going-to-get-this-type-of-care-in-these-types-of-situations,’ that’s something that usually should be disclosed in an insurance contract.

FM: Baker encourages people to challenge their health plans -- by calling the Attorney General’s healthcare complaint line and by exercising their right to appeal. In New York, consumers who push hard enough can get external, independent appeals. Only a small fraction of people challenge HMO decisions, but many of those who do, succeed.

A side note to this story. OrthoNet was prepared to talk about the case of the toddler with tight joints, but could not, for patient-confidentiality reasons…For more on OrthoNet, physical therapy, and how to get the most out of your health insurance, tune into the Brian Lehrer Show today and tomorrow at 10 am.