Changes in physiotherapy use for MSDs highlight inequality of access

Access to primary care is central to Canada’s universal health-care system. But not all workplaces provide health-care benefits to fund physiotherapy services. In Ontario since 1994, physiotherapy has been considered primary care, but the mix of private and public funding for physiotherapy treatment has been in flux.

Provincial health-care plans increasingly restrict insurance coverage for physiotherapy services. For example, in 2005, the Ontario Health Insurance Plan (OHIP) restricted its funding; publicly funded, community-based physical therapy (PT) services offered through Ontario's network of providers were partially delisted in April 2005. Services remaining include those for the following: seniors; those age 19 and under; residents of long-term care homes; those needing physiotherapy services in their home or after being hospitalized; Ontario Disability Support Program, Family Benefits and Ontario Works recipients.

The potential for unequal access exists for those not privately insured or in workplaces without coverage.
In debates over access to essential or “medically necessary” care, comparatively little attention has been paid to the funding of physiotherapy services. This study sought to provide a clearer picture of physiotherapy use and funding among workers with musculoskeletal disorders (MSDs) in one large workplace.

The study examined physiotherapy use and funding for MSDs among 2,000 employees of a large, unionized newspaper in Ontario. Researchers retrieved billing information about MSD-related physiotherapy services from three payers: the Workplace Safety and Insurance Board (WSIB), the newspapers’s private health insurance carriers, and the workplace itself. Starting in 1995, the workplace reimbursed employees up to $1,500 a year for MSD treatment. As of 1997, it also provided and paid for on-site physiotherapy. The researchers looked at physiotherapy use and costs by quarter, over the period 1992 to 2002.

The researchers noted a substantial rise in physiotherapy use to treat MSDs in this workplace over the 10-year period. An average of 234 physiotherapy services per quarter during the years 1992 to 1994 increased to 1,281 per quarter in 1999 to 2002.This increase in use was accompanied by a shift in payer, from the WSIB and health insurance carriers to, initially, the workplace fund to reimburse costs and then to the employer-paid on-site service. Average costs per quarter for physiotherapy services also increased, from $4,740 per quarter in 1992 to 1994 to $52,134 per quarter in 1999 to 2002. The researchers speculated that the affordability and accessibility of the workplace-funded physiotherapy, along with an active workplace campaign to promote early reporting and treatment of MSDs, accounted for the increase in use and costs.

Pointing to systematic reviews that confirm the effectiveness of physiotherapy, the researchers concluded that physiotherapy should be accessible to working-age adults with MSDs. However, since provincial health insurance programs have become more restrictive and most workplaces do not provide the level of funding and services offered by the newspaper, the potential exists for unequal access to physiotherapy services among workers not privately insured or covered by their workplaces.
The growing dependence on private physiotherapy services for working adults may warrant a closer examination of the services covered under universal health-care schemes.

A major strength is that this study provides an important benchmark for Canadian research on the funding of physiotherapy services. A weakness of the study was its inability to obtain OHIP data, which likely led to an underestimation of the total use of physiotherapy.