International Journal of Physical Medicine & Rehabilitation
Open Access
ISSN: 2329-9096
ISSN: 2329-9096
Mini Review - (2025)
In the fragmented and often inaccessible U.S. healthcare system, individuals with catastrophic injuries and chronic impairments frequently rely on legal proceedings to secure funding for long-term medical care. Accurate medical projections are essential to these legal processes, yet most medical professionals lack the specialized training to assess and forecast lifelong care needs and costs effectively. This paper argues that physiatrists, physicians specialized in physical medicine and rehabilitation are uniquely qualified to perform this role due to their multidisciplinary training, longitudinal patient management, and expertise in functional impairment, rehabilitation, and cost estimation. This manuscript outlines a rigorous, peer-reviewed methodology physiatrists can apply to project future care requirements, costs, impairment ratings, and life expectancy in a legally defensible and clinically grounded manner. It further explores how systemic healthcare failures have positioned the legal system as a de facto provider of long-term care and why physiatrists must remain central to ensuring medically appropriate and economically justified outcomes. As the healthcare landscape grows increasingly complex and inaccessible, physiatrists serve as critical intermediaries in both clinical and legal contexts, bridging the gap between need and access.
Physiatry; Catastrophic injury; Future medical care costs; Rehabilitation medicine; Life expectancy estimation; Disability evaluation
Appropriate methodology is required to determine impairment, disability, cost for future medical care and life expectancy, which is defined in a comprehensive rehabilitation evaluation.
The legal system serves as a critical pathway for accessing medical care, services, and equipment in the context of a deeply fragmented U.S. healthcare system. For individuals with catastrophic injuries or disabling conditions, accurate and individualized medical evaluations are essential to determining the level and cost of care required over a lifetime.
Unfortunately, projecting future medical needs and associated costs is highly complex. It requires not only clinical expertise but also multidisciplinary knowledge of rehabilitation, healthcare systems, and cost structures. As a result, even the most skilled diagnosticians and interventionalists tend to lack the training and experience to develop high-quality, long-term cost projections. Physiatrists, however, are uniquely positioned to perform this critical function.
Here we describe why physiatrists, physicians specializing in physical medicine and rehabilitation, are the most qualified experts to provide legal determinations regarding compensation for long-term care in catastrophic and non-catastrophic cases. We also examine how systemic healthcare failures have made this role increasingly difficult for ensuring access to medical care, services and equipment.
Physiatrists are trained to anticipate and manage long-term care needs
Primary care physicians and nurses are generally inconsistent and neither accurate nor precise in predicting life expectancy in individual patients [1]. However, physiatrists’ training, clinical practice experience, and focus on care coordination makes them ideally suited to not only predict life expectancy but to also understand the medical needs across the lifespan and the costs associated with those needs.
Physiatrists are Medical Doctors (MDs or DOs) who specialize in the diagnosis, treatment, and long-term management of patients with functional impairments resulting from injury, illness, or chronic disease. Becoming a physiatrist requires a rigorous and specialized training path that includes.
An undergraduate degree: Four years of premedical coursework.
Medical school: Four years of general medical education, including clinical rotations across different medical specialties.
Residency in Physical Medicine and Rehabilitation (PM&R): Four years of hands-on, specialty-specific training in rehabilitation medicine, including rotations in spinal cord injury, brain injury, musculoskeletal disorders, pain management, and complex care coordination.
Board certification: After completing residency, physiatrists must pass rigorous written and oral board examinations administered by the American Board of Physical Medicine and Rehabilitation.
Fellowship: Many physiatrists complete additional fellowships in pain medicine, brain injury, spinal cord injury, or pediatric rehabilitation to further specialize their practice.
This extensive education and medical training provides physiatrists with uniquely comprehensive knowledge that enables them to assess long-term disability, anticipate clinical complications, design clinical care plans, and coordinate multidisciplinary rehabilitation services across a patient’s lifespan.
Physiatrists that have extensive clinical practice experience are also skilled at synthesizing complex clinical information into cohesive, forward-looking assessments that account for the dynamic nature of disability progression. Physiatrists are therefore deeply familiar with the real-world clinical trajectories of patients with complex needs, as well as with the medical, logistical, and financial tools needed to manage those needs over time [2].
By assessing how impairments raise the risks for complications and lead to long-term disabilities, physiatrists identify interventions to slow or prevent physical, cognitive, and mental decline. They also gain extraordinary expertise in the need for durable medical equipment, environmental adaptations, and support services. Unlike many specialists, physiatrists maintain a longitudinal view of patient outcomes, following individuals over years or decades to understand how needs evolve and how interventions perform over time. Their familiarity with both the clinical and cost landscapes allows physiatrists to provide realistic, detailed cost estimates. These projections are rooted in clinical expertise, peer-reviewed medical literature, and real-time data from service providers and vendors.
Physiatrists should follow a methodology for projecting future medical needs and costs
To support fair legal outcomes, evaluations of future care needs must meet rigorous standards of clinical rigor, individualized detail, and legal admissibility. Additionally, for medical cost projections to be accurate, costs must reflect actual retail prices, not insurer-negotiated rates or public reimbursement figures. Incorporating these real-world costs into legal evaluations is essential to ensure fair compensation, particularly in states that limit the admissibility of any collateral source evidence to reduce actual cost [3]. However, some states now allow or even require the trier of fact to consider what a health insurance carrier would pay for the requisite future care and treatment, which may require the author of the plan to be familiar with and cite these reimbursement rates for covered services.
Physiatrists should follow a structured methodology designed to ensure their evaluations meet these requirements
Step 1: Clinical evaluation
• Detailed history and intake: The physiatrist begins by reviewing the patient’s medical history, injury details, and current level of functioning. He or she analyzes records, rehabilitation notes, diagnostic studies, therapy reports, and prior expert opinions when available to fully understand the patient’s trajectory of needs. Family interviews are often conducted to supplement gaps in the provision of care or provide additional context when analyzing all future medical needs.
• Physical examination or direct observation: When possible, a full in-person exam and/or patient observation is conducted to assess motor and sensory skills, cognitive status, and physical capacity.
• Functional and complication risk assessment: Using standardized clinical tools, the physiatrist identifies secondary complications (e.g., skin breakdown, contractures, deep vein thrombosis, pulmonary embolism, urinary tract infections, seizures) and evaluates the likelihood and timing of these risks based on diagnosis and condition severity.
Step 2: Utilizing peer-reviewed literature: Demonstrating medical opinion consistent with peer-reviewed literature
• Contacting treating and evaluating physicians: When possible contacting treating and evaluating physicians for information that may not be contained in medical records, in an effort to have accuracy at a premium.
• Service mapping and duration forecasting: The physiatrist identifies each service, device, or intervention the patient will require, specifies the frequency and duration of use, and justifies the recommendation with peer-reviewed medical literature or clinical precedence.
• Localized cost estimation: Using geozip data, the physiatrist sources retail (usual and customary) pricing for each service in that patient’s locality. Adjustments are made for medical inflation, service frequency, and individualized life expectancy.
• Documentation and standards compliance: The final report includes clear, evidence-based justifications for each component of the projection. It is prepared to meet the applicable standard for admissability (e.g., Daubert or Frye), ensuring it is scientifically valid, peer-reviewed, and legally admissible.
Step 3: AMA rating
If an impairment rating is required, the most up-to-date version of the American Medical Association (AMA) Guidelines to the evaluation of permanent impairment should be utilized.
Step 4: Disability
Based on the ongoing functional limitations, physiatrists assess the level of disability impacting the patient’s capacity to perform daily activities and occupational tasks. The evaluation aims to determine how the impairment limits the patient's capacity to perform these activities independently. With a physiatrist’s extensive clinical practice experience, which involves providing aid and attendant care to many disabled people, the physiatrist should be able to define safe parameters for a patient to return to the workforce or define the amount and level of aid and attendant care needed. If possible, physical functional testing equipment and protocols such as BTE or the biodex have peer-reviewed evidence to support their normative data. In the medical and legal context utilizing peer-reviewed published normative data and validity testing will withstand legal challenges such as allegations of junk science.
With functional testing using normative data and validity testing, a patient’s disabilities can be accurately defined, which can further substantiate the physiatrist’s opinion.
Step 5: Life expectancy
Physiatrists consider the patient’s underlying condition, comorbidities, and established actuarial data to estimate life expectancy. While individualized factors are taken into account, the projection remains aligned with current epidemiological benchmarks for similarly affected populations and consistent with information from peer-reviewed medical literature and the physiatrists’ clinical experience. This nuanced process ensures life expectancy estimates are neither overly optimistic nor unjustifiably conservative, preserving fairness in compensation.
This methodology ensures an output that reflects not just theoretical knowledge but also the daily clinical realities that physiatrists navigate in their practices. Physiatrists’ insights are key not just for medical planning, but increasingly, for legal decisions, as the U.S. healthcare system continues to leave many patients without adequate coverage. Physiatrists’ dual fluency in clinical care and real-world costs makes them particularly credible in legal proceedings, where both domains must be reconciled.
The legal system has become a surrogate for healthcare access
The broken healthcare system in the United States leaves many individuals, especially those with catastrophic injuries and disabling conditions, unable to obtain necessary medical care, services, and durable medical equipment [4-7]. Many of these needs fall outside the bounds of traditional insurance coverage or are poorly reimbursed [8]. Rising out-of-pocket costs and insufficient coverage options place these services entirely out of reach for a growing number of Americans. As a result, the legal system often serves as the only viable avenue for securing essential medical care, services, and medical equipment [9].
Legal proceedings have become a parallel mechanism for care allocation, one that operates outside the traditional healthcare infrastructure. For these patients, fair and effective legal outcomes rely on accurate, defensible medical evaluations of their current condition, future care needs, and associated costs. As discussed above, projecting these costs is complex [10-12].
In certain contexts, through litigation, patients are entitled to obtain financial compensation that can fund their future medical care. Legal decisions regarding damages and compensation hinge on expert evaluations of a patient’s medical status and projected care needs. These evaluations must forecast what services a patient will require over the course of their lifetime, how often they will need them, and what those services will cost in the patient’s geographic area. Courts must assess whether the evidence is credible, individualized to the specific patient, and sufficiently detailed to justify the projected costs.
To meet these standards, those providing supporting evidence for patient care and coverage must not only have the relevant medical education and training but must also have clinical practice experience to understand long-term disability trajectories, potential complications, significant functional impairments, and evolving standards of care [2]. In addition, the ability to integrate insights from interdisciplinary care teams and apply this knowledge within the legal context is essential to producing defensible, realistic, and useful evaluations.
Knowledge of peer-reviewed medical literature that provides insight beyond clinical practice experience and understanding of regional cost variations are also critical.
Physiatrists will remain essential for legal cost projections in a broken U.S. healthcare system
Despite technological advances and shifts in healthcare delivery, the role of physiatrists in projecting long-term care needs and costs will only become more critical over time, as the U.S. consistently underperforms in health outcomes and access, even as it is the highest spender on healthcare globally [13]. In 2023, healthcare spending reached $4.9 trillion, or $14,570 per capita, accounting for 17.6% of the nation’s gross domestic product [14]. Yet, life expectancy continues to lag behind other high-income countries, at just 78.4 years [15].
For millions of Americans, medical debt is both a barrier to healthcare and a driver of deteriorating health, underscoring the critical role of physiatrists in helping these citizens gain access to medical care [16–18]. Healthcare debt is one of the most visible and devastating consequences of these system failures. Approximately 23 million adults owe more than $250 in medical debt, and nearly half of U.S. adults report difficulty affording healthcare costs. The emotional, physical, and economic toll of healthcare debt is profound. It leads to avoidance of healthcare, worsened chronic conditions, increased mental health struggles, and long-term financial instability.
This disconnect between spending and outcomes highlights the deep inefficiencies within the U.S. healthcare system. A significant portion of U.S. healthcare expenditure goes toward administrative overhead, inflated service pricing, and fragmentation of care rather than prevention [19,20]. As a result, many patients struggle to access even basic services. The consequences are particularly dire for those whose medical needs are long-term, complex and multidisciplinary [21].
These systemic issues are not expected to improve. The U.S. continues to face rising labor and supply costs, constrained reimbursement, and widespread staffing shortages, all of which drive consolidation and shift care delivery in a manner that exacerbates access challenges for those with catastrophic injuries and disabilities [22]. As health systems contract and reorganize, access to long-term care is becoming more fragmented and more dependent on patients’ financial resources.
Paradoxically, as medicine advances, care for those with complex needs does not necessarily improve. For instance, despite rapid progress in digital health, artificial intelligence, and outpatient care models, patients requiring intensive, continuous support are often the least likely to benefit from these innovations [20]. The result is a growing population for whom medical need remains high, access is increasingly restricted, and legal pathways are often the only viable route to secure necessary care.
In this evolving landscape, physiatrists’ expertise in forecasting future care needs and costs remains indispensable. Their ability to understand long-term functional decline, anticipate complications, and quantify real-world costs positions them as essential contributors to fair legal outcomes and to access care itself.
The U.S. healthcare system is failing to provide adequate and sustained care for individuals with long-term catastrophic medical needs and patients who may not have a catastrophic injury but have a clinically significant injury that requires ongoing chronic pain management. In this widening gap, litigation often becomes a de facto healthcare delivery mechanism. Legal outcomes depend on reliable, scientifically grounded projections of what patients need and how much it will cost.
Physiatrists are uniquely positioned to offer these projections with accuracy and credibility. Their role is critical not only in defining what care looks like, but in making that care attainable through the legal system. As the nation continues to confront health inequities and fiscal strain, the credibility and foresight offered by physiatrists will be vital to ensuring that justice, both legal and medical, is meaningfully served. In a fractured and financially strained system, their expertise may determine whether patients live with dignity and support or continue to fall through the cracks.
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Citation: Lichtblau C, Pettingill B (2025). The Physiatrist is Essential to Predicting Accurate Future Medical Care. Int J Phys Med Rehabil. S30:001.
Received: 02-May-2025, Manuscript No. JPMR-25-37478; Editor assigned: 05-May-2025, Pre QC No. JPMR-25-37478 (PQ); Reviewed: 19-May-2025, QC No. JPMR-25-37478; Revised: 26-May-2025, Manuscript No. JPMR-25-37478 (R); Published: 02-Jun-2025 , DOI: 10.35248/2329-9096.25.S30.001
Copyright: © 2025 Lichtblau C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original auth or and source are credited.