International Journal of Physical Medicine & Rehabilitation
Open Access

The Role of Physiatrists in Ensuring Access to Appropriate Medical Care and Services in the Broken USA Healthcare System

Craig H Lichtblau^1* and Bernard Pettingill^{2 *}Correspondence: Craig H Lichtblau, Medical Director of the Osseointegration Program at The Paley Orthopedic and Spine Institute, St. Mary’s Medical Center, West Palm Beach, FL, USA, Email:

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Introduction

Exorbitant healthcare costs in the U.S. paired with inferior health outcomes compared to other high-income nations has led the U.S. to be ranked 37^th in the world for access to quality care [1]. Those requiring long-term care are faced not only with unaffordable care costs but also the challenge of predicting and planning for lifetime costs of care. Physiatrists are well-positioned to help this group of patients, as these physicians are experts at the intersection of clinical care and care costs. They can thus predict both the clinical evolution of the patient’s conditions as well as cost realities across the short and long-term.

U.S. Healthcare spending exceeds those of other highincome nations with worse outcomes

U.S. healthcare spending was $74.1 billion in 1970 [2]. By 2021, it had reached $4.3 trillion and exceeded 18% of our Gross Domestic Product (GDP) [3]. The U.S. outspends other first world nations in healthcare but suffers worse health outcomes.

For example, people living in countries that spend less on healthcare per capita compared to the U.S. are expected to live longer than those living in the U.S.

In 2021, while life expectancy in the U.S. was 76.1 years and healthcare spending per capita was $12,914, life expectancy in Japan was more than 8 years greater (84.5) and healthcare spending per capita was only $4,666 [2]. In the same year in the UK, where life expectancy was 80.8, per capita healthcare spending was $5,387.

It is thus unsurprising that after a publication in the New England Journal of Medicine warned that the U.S. healthcare system ranked 37th in the world, it was noted in JAMA that the U.S. healthcare system ranks last among highincome countries in terms of access to care, despite spending more of its GDP on healthcare [1,4].

Several factors contribute to the lack of balance in cost and quality in U.S. healthcare, including lack of transparency around cost of healthcare services and consolidation of hospitals and insurers [5-7]. Unfortunately, while there is little sign of emerging improvements in health outcomes in the U.S., experts agree that U.S. healthcare spending will continue to increase in the future, exacerbating the barriers to affordable quality care.

Americans are forced to Choose between obtaining Vital care and avoiding medical Debt

According to researchers from Harvard Medical School, 45,000 Americans die annually due to a lack of health insurance [8]. By 2023, 73% of Americans reported that the U.S. healthcare system was failing them, with lack of affordability identified as by far the largest problem with the system [4,9]. Notably, many of the 26 million people in the U.S. who were uninsured in 2022 were eligible for coverage but unable to afford insurance due to rising premiums [6,10].

While millions of Americans are uninsured, focusing on the number of uninsured masks the magnitude of the unaffordability of U.S. healthcare, as many individuals cannot afford necessary care despite being insured because their coverage does not adequately protect them from healthcare costs [11]. While low-income families in the U.S. often cannot access healthcare, many in the middle class are subject to a lose-lose scenario wherein they may be insured but with little financial protection due to their structure of deductibles, copayments, and loopholes for avoiding coverage [12].

Between the uninsured and the underinsured, 23 million people are in medical debt in the U.S., with their total debt exceeding $195 billion [3]. Bankruptcy and premature withdrawals from retirement’s savings are frequent consequences of medical debt [13]. More than 66% of those who declare bankruptcy cite medical reasons as the cause, and medical bills lead more than half a million families to go bankrupt annually in the U.S [14,15]. This medical hardship millions of Americans currently face is expected to rise as healthcare continues to outpace income increases [16-18].

In addition to its financial toll, the lack of affordability of U.S. healthcare is also a major source of anxiety for American families. According to Gallup, 46 million Americans could not afford the necessary care in the case of a medical emergency, leaving half of all people in the U.S. reporting fear that a medical event could bankrupt their family [19]. Considering whether to pursue critical healthcare for oneself or a loved one or to avoid crushing medical debt is both a real and hypothetical exercise for people in the U.S., despite the nation’s high-income status.

The court system serves as a Gateway for many americans to Access medical care

The court system is a major avenue through which many Americans especially those who have suffered personal injuryultimately receive the financial support required to obtain the healthcare services they need to prevent rapid health deterioration and premature death and to optimize functioning and quality of life. A prerequisite of this support is a clear and reliable assessment of the future medical costs associated with the care needed to minimize suffering, increase functioning, and avoid premature death [20]. It must be realized that pain is inevitable, but suffering is optional. The goal of defining accurate medical and support care is to decrease suffering, especially as we age.

Defining future medical care is complex because it requires not only clinical expertise and knowledge of medical costs, but also deep insight into how the risk of specific comorbidities and complications will affect costs over the long-term and in relation to the physical location of the patient. With respect to the latter, retail prices in specific zip codes are required to calculate a patient’s financial needs, and it is laborious to find and verify these figures [20,21].

The methodology for determining future medical costs therefore involves

Clinical assessment, including evaluating patient history, performing patient observation and/or performing a physical examination, reviewing pertinent medical records, and consulting with the patient’s other treating specialists, if necessary.

Peer-reviewed literature assessment, including but not limited to understanding and providing peer-reviewed literature that supports medical opinions, combined with extensive clinical practice experience taking care of patients to provide accuracy at a premium.

Cost assessment, including evaluating costs of specific medical services based on the potential need for those services and the retail prices of those services in the patient’s location.

In the context of litigation, if these steps are followed, one should meet the differing requirements across state and federal courts, which govern the admissibility of expert testimony. While these requirements vary from state to state, they are all designed to ensure that expert testimony is reliable and based on credible scientific principles and methods.

Physiatrists are ideally Positioned to help interested Third parties understand a Patient’s future medical costs

Physiatrists are experts in the long-term treatment and management of patients with catastrophic and non-catastrophic injuries and conditions [22]. Their patients frequently suffer from traumatic brain injury, spinal cord injury, stroke, amputation, burns, progressive neurologic diseases, and musculoskeletal conditions and are subject to chronic pain and a host of medical complications. In addition to clinical knowledge, physiatrists harbor expertise in costs related to diagnostic tests, support care, medical interventions, surgical procedures, medical equipment, home modifications, mobility devices, and transportation [22].

Physiatrists are responsible not only for defining these patient’s impairments and treatment plans but also for considering how these patients can best reintegrate back into society given their specific challenges and health-related risks, what costs patients will face for their medical care, and how long they are expected to live. This Comprehensive Rehabilitation Evaluations (CRE) serve as forensic medical reports when parties outside of medicine, such as insurance companies, attorneys, judges, and/or juries, require accurate information on the patient’s condition, prognosis, costs of future medical care, and life expectancy.

Discussion

The value of decisions of those outside of medicine often rely heavily on the accuracy of these CREs, making it imperative that CREs are only developed by those with the qualifications to provide the clinical realities at hand and their associated costs over the patient’s lifetime [22]. Unlike other clinicians who may adequately diagnose and treat patients, physiatrists are trained to understand which medical conditions will continue to affect future healthcare costs and how, as well as to assess a patient’s life expectancy and its impact on lifetime costs. These latter skills are integral to translating patient’s clinical conditions into projected lifetime healthcare costs and ensuring that decision makers allot appropriate funding for such care.

In light of the amendment to Rule 702 of the Federal Rules of Evidence, signed into law on December 1, 2023, regarding whether or not an “expert opinion reflects a reliable application of the principles and methods to the fact of the case”, we believe that it is imperative to use the correct formula for providing the money needed to finance a lifetime of care. With that in mind, there are several variables that have to be considered, namely, the life expectancy (normal or reduced based on the severity of the injury), historic growth of medical maintenance expenses, as measured by the U.S. Department of Labor, and the investment rate, derived from a source of risk-free United States Treasury backed securities, which have never defaulted and which provide a safe road for financing the future care of each and every patient. With this in mind, a medical/forensic economist can set forth the parameters in order to reduce to present value and to provide the jury with a reasonable sum of money to adequately finance the damages in each and every case.

Conclusion

In the broken U.S. healthcare system, millions of Americans forgo critical care because of the crushing costs associated with providing that care. At the same time, many of those who pursue appropriate care end up in exorbitant medical debt or declaring bankruptcy. Accurately and comprehensively predicting lifetime costs of care can help ensure appropriate planning including securing necessary funding for that care. Physiatrists are trained in both the clinical and cost aspects of care, as well as how clinical realities and costs interact. These groups of specialty physicians are thus ideally suited to contribute to the accurate projection of lifetime care costs to ensure patients can access and afford the critical care they need.

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