Rehabilitation Considerations for Post-Surgical Patients during the Covid-19 Crisis

Commentary

The COVID-19 crisis has been a scare to countries, states, counties, and neighborhoods across the world. At the time of this writing, universities are shunning students from their classrooms, hospital beds are still near their limits, and the number of diagnosed positive Coronavirus patients continues to climb in the United States. Despite the increase in Coronavirus patients, physicians have resumed performing elective surgeries.

Elective surgeries are defined as any surgery that is planned, rather than something related to a trauma or an emergency. This can include cosmetic surgeries as well as joint replacements or other orthopedic surgical interventions in order to improve function and/or provide pain relief.

Elective surgeries are a key cost driver for hospitals and surgery centers. One analysis performed3 showed that the average revenue from back surgery was between $50,000 and $90,000. Single knee replacements brought in approximately $30,000. The same analysis produced data showing that between March 2020 and April 2020, elective surgeries were down sixty-five percent compared to the same time period in 2019. While these numbers are staggering to the financial officers who oversee these hospitals and surgery centers across the United States, we must also consider how the reduction in elective surgeries has affected the physical therapy profession both in physical therapy number of visits, the physical therapist workforce, and how this will affect patients who are returning for elective surgeries only to find a reduced availability of physical therapy providers to assist them in pain management, and in rehabilitation to a proper return to function.

Commentary

In 2019, the Bureau of Labor Statistics projected that for the years of 2018-2028, the physical therapy profession would grow by approximately thirty-four percent (34%) [1, 2]. At the time of this writing, that number for the years 2019-2029 has been adjusted to eighteen percent (18%). Layoffs and furloughs of physical therapists and physical therapist assistants became common place beginning in March 2020 due to COVID-19, after many were laid off from skilled nursing facilities and home health agencies due to reimbursement changes in 2019. Compared to the period of March-April 2019, physical therapy visits dropped by 35 percent (Consumer Medical). Many outpatient clinics changed payroll models to a pay per visit model, pay per hour, reduced PTA staffing entirely, and attempted to adjust in several other ways. An April-May 2020 APTA survey [1] described clinically-specific data related to the effects of COVID-19 on the PT and PTA workforce, looking at adjustments to telehealth, hours worked, lost revenue, etc. A question remains, though: how has the shifting effect of the PT and PTA workforce and job market affected the elective surgery patient population.

Even while physical therapists and physical therapist assistants are seeing an uptick in visit numbers according to a July APTA survey, numbers are far from optimal. Elective surgeries have increased by 40-60 percent in the month of May 2020 compared to February [3], while therapist availability remains relatively low. In order to know the effects of the workforce dynamic on patients, we need to look at the types of elective surgeries that are being performed, the average number of visits typically performed on these types of patients to discharge or return to prior level of function, and alternative types of care for these patients.

In home health physical therapy the average caseload of patients being seen at any one time was approximately twenty-one patients. The optimal number of PT visits is six to nine visits5 with the average length of a home health knee replacement rehabilitation episode being fourteen to twenty-one days before being discharged to outpatient physical therapy [4, 5].

With the increasing number of elective surgeries being performed, knee replacement surgery has been one of the top five elective surgeries to bounce back during the COVID-19 pandemic. Expectations are that elective surgeries will reach near ninety-five percent (95%) above pre-COVID levels [6]. The slowly increasing number of therapists returning to work is not enough to meet the needs of the rehabilitation population [1]. COVID-19, along with the impending reimbursement cuts from the Center for Medicare and Medicaid services for PT and PTA provided services in outpatient, has caused a large disparity of care for those who are electing surgical procedures requiring rehabilitation. The danger of this scenario is the potential for surgical revisions, manipulations, patient debilitation, falls and other sequelae that will cause greater cost and rehabilitation to an already weakened system. Patients who choose elective surgeries should have the comfort of mind to know that their progress and prognosis will not be hindered by anything that reimbursement reductions or a virus pandemic may have caused on a therapy workforce. It is the responsibility of rehabilitation clinicians everywhere to be as creative as possible with evaluation and treatment options, to be creative with how therapy services are economically delivered for optimal profit and optimal patient outcomes, and to prevent patient re-hospitalization.