We've seen the growth of networks that purportedly seek to have the best interests of the PT profession in mind, but even these require significant membership fees to join and in many cases, are powerless to control PPO stacking-another reimbursement-reducing tactic. The fact is, life for the independent physical therapy practice owner is becoming complicated and fraught with potential hazards.
On a more optimistic front, PTs are learning new ways to generate income streams less reliant on traditional insurance-based reimbursement, and emphasizing more cash-based programs. Clinics around the country are showing that physical therapists have the creativity and staying power to not only survive the sluggish economy and health care reform, but also to thrive in these suboptimal circumstances.
Private practices are embracing wellness initiatives for several good reasons, not the least of which is that patients are expecting a wellness approach to their health care. People are spending money on improving their health, productivity and longevity, and are anticipating that health practitioners also incorporate preventive, holistic strategies into their delivery structure.
For physical therapists, this means recognizing we are not simply treating knees, shoulders and spines, but rather the dynamic and complex inter-relationship between a person's pain or therapy diagnosis, and his environmental, biological, psychological and social determinants.
The cost drivers in rehabilitation are often those areas that bring or add cost to health care in general. They are the "epidemics" that public health and clinical community members are vexed to solve, which create an enormous economic burden for society in general: diabetes, cardiovascular disease, many cancers, obesity and COPD are of growing concern, to name a few.
Within our physical therapy centers-Quantum Physical Therapy Centers of Southeastern Michigan-we tracked and identified how factors such as heart disease, diabetes, COPD and obesity can significantly impact patient outcomes since these factors can limit movement and activity in general. These problems or co-morbidities are, in many cases, the cost drivers in rehabilitation for common conditions such as total knee/hip arthroplasty and virtually any orthopedic musculoskeletal problem that is referred to physical therapy.
Transforming Provider and Patient
Physical therapists are in a prime position to become the "experts" in health and wellness. The nation is undergoing a painful process of change, and therapists can be leading the way as the primary providers of wellness-based services. Even small centers can become effective providers of wellness services, beginning with offering health risk assessment (HRA).
This tool forms the basis for any disease management company's database, in combination with medical claims, pharmaceutical and biometric data from PCP-based annual physicals. PTs will not have access to much of that data, so administering the HRA will be critical to data collection and understanding the needs of your wellness client.
With this data in hand, therapists can begin to understand some critical variables of interest-not only past and present medical history, but readiness for change, attitudes, values, motivations and interests.
Disease-management companies are charged with analyzing the composition of the population to which they're contracted to provide services. As one specific example, in a large auto manufacturing plant, our clinic sees healthy people, those at risk for disease and people who have overt disease. This broad categorization will allow health coaches and on-site case managers to target specific interventions.
The goal of disease management is to prevent progression of disease and associated escalation of costs that might occur with an ER visit leading to an episode of hospitalization. If a PT has a recent HRA of a client, the data can be used to estimate the risk rating of stroke, MI and other events.
So much of employee health management has to do with behavioral change and educating/coaching people into making the best decision for their health. Behavioral change is probably still best performed one on one, face to face. Digital tools are becoming more important as adjuncts in this process. There is great debate whether web-based approaches can eventually supplant the need for a face-to-face intervention, with evidence suggesting that in a self-directed individual who is motivated to change, a digital format of education, intervention and coaching can be effective.
As wellness providers, it's incumbent on us to be sensitive to these differences between people, and to have an assessment tool with the ability to capture this readiness for change. This step is an important part of the population demographic analytics that must be performed at every corporate setting.
This is where the value of a one-on-one or face-to-face strategy is unmatched in building trust and instilling confidence in members. In cases where a face-to-face model is not feasible, web-based tools can serve as valuable adjuncts, but are limited to members of the population who tend to be more self-directed and motivated.
Web strategies don't work as well for those not inclined to use electronic and digital media, either because of access issues, low motivation or a preference for a human approach. Central to most behavioral-change paradigms is the idea of self efficacy, or empowering people to take control of their own problems by providing them with valuable tools. Recognizing who can benefit from which intervention is critical in design and implementation of wellness deliverables to a population.
Expanding the PT Paradigm
With health care reform imminent, partly as a result of escalating health care expenditures, people are being incentivized to make healthier decisions and take more responsibility for the state of their own health. We are seeing this trend especially in the workplace, with onsite and offsite wellness becoming a popular benefit for employees while the employer indirectly reaps the benefits of a more productive employee population.
Physical therapists must capitalize on this trend to help ensure their future survival. Health and wellness initiatives are good for our clients, employer sponsors and the provider community charged with delivering these critical services.
Our clinical data strongly suggests that co-morbidities are partly to blame for our extreme or "outlier cases"-those that require longer therapy utilization (treatment duration) and service intensiveness in general. Patients who are obese, diabetic, have cardiovascular disease and/or COPD tend to take longer to rehab across all diagnostic groups, as compared to their healthier cohorts.
Knowing this, our rehab company began to offer smoking-cessation, weight-management and post-therapy exercise prescriptions to our patient population. We expanded this short list to include stress-management and adjunctive drug-dependency protocols to deal with postsurgical narcotic dependency. Protocols are simple, effective, easily administered and well-tolerated by patients. Referring physicians appreciate that someone in the rehab continuum is actually addressing this often difficult-to-treat and stigmatizing condition. We use a proprietary auriculo-therapy approach similar to the NADA protocols being used in detoxification hospitals.
With powerful tools for change, the PT practitioner is poised to become a transformative agent in the life of a patient. With an expanded set of tools such as behavioral frameworks, auriculotherapeutic techniques, understanding fundamental exercise principles and a few formula calculations for caloric expenditures and BMI, the PT is armed to offer some core wellness deliverables at a basic level.
The beauty of this expanded model is that PTs already have the space, equipment and expertise to implement these services. If we don't capture this opportunity, some other group will. Exercise prescriptions for orthopedically challenged patients are best provided by a well-trained physical therapist combining exercise science with biomechanics and pathophysiology.
An Integrated Model
Health care reform is sure to refocus our efforts to emphasize prevention strategies in a more proactive and patient-directed health care delivery model. The old system is a reactive model that reimburses for health care services after a patient has become sick, injured or diseased.
We've tried to improve the efficiency of this system through managed care paradigms, peer-review processes, pay-for-performance schemes, third-party utilization audits and similar initiatives that try to contain costs, reward good outcomes and control supplier-induced demands in health care.
It's finally been realized by health policy legislators that none of these initiatives are enough without proper allocation of health care resources to prevention efforts. It's this prevention effort that's central to health and wellness programs.
Health education, promotion and initiation all require expert delivery and implementation efforts, preferably by trained health professionals.
Independent physical therapists in the private sector are optimally positioned to be part of this national effort in offering not just reactive rehabilitation services, but also more cost-effective and practice-enhancing proactive services that address the global risk factors contributing to those diseases that cause high rates of mortality.
Specifically, PTs can offer HRAs to patients and follow up with a risk analysis and summary report containing specific intervention options. There are numerous onsite interventions that PTs can offer with a proven high return on investment. For example, health coaches can be taught how to recognize and intervene early when there is the beginning of joint or muscle pain.
These are potential medical/rehab cases and it may sound counterintuitive and generally bad for the rehab business to intervene early and prevent progression to injury. However, the benefits (cost savings) of a prevention approach become so obvious to both employee and employer that eventually this source of income might supplant traditional insurance-based reimbursements.
Another way to view it is prevention as a logical progression from where we are today. If PTs don't respond to the collective calling for professional health and wellness advisors, someone else most certainly will.
Tiziano Marovino is vice president of health strategy and innovation for Biogenesis Group, a subsidiary of Quantum Physical Therapy Centers in Michigan. Biogenesis Group trains and certifies health coaches, collects and disseminates health data, and operates a corporate wellness provider network. Visit www.biogenesisgroup.com