A pal told me recently that their very expensive, very shiny insurance had approved them for physio. It sounded great. Unlimited sessions. All taken care of. Cushty.
I smiled, nodded and quietly thought: that's definitely not how this works.
When something sounds too good to be true, it usually is.
Because behind that promise sits a very different reality.
For years we were told the same thing: measure outcomes, prove quality and the system will reward it. I was part of that push. A group of us sat with major insurers trying to move the conversation away from blunt session averages and towards data-driven outcomes that demonstrated quality. Pay for results, not volume. That was the idea.
So we did it. PROMs, audits, data collection. Solid stuff. Some insurers even nodded along and lightly "mandated" it.
Nothing really changed.
Fees have barely moved. In real terms they've gone backwards. Meanwhile the message to patients has become simpler and more reassuring. You've got sessions. If you need more, your physio can just extend it.
But in the clinic, you're managing that tension from day one. You know where the soft ceilings sit. You know when you're drifting into justification and forms and processes that look like decision-making but rarely are.
So you end up with two versions of the same system. One sold to the patient. One lived by the clinician. They don't quite match and that's where the problem sits.
When expectations and reality diverge, trust takes the hit. Quietly. Over time.
The profession has pushed on this for years and nothing really shifts. Behaviour adapts. Not because clinicians want it to, but because the system points that way.
And once that happens, it's no longer about outcomes. It's about staying within the lines.
If the story being told and the reality being delivered don't line up, something is broken.