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INTEGRATING A “PT FIRST” APPROACH IN EMERGING
HEALTHCARE MODELS
Chuck Thigpen, PhD, PT, ATCBridget Morehouse, PT, MBATom Denninger, PT, DPT, OCS, FAAOMPT Chris Stout, PhD
Disclosure
No relevant financial relationship exists
Session Learning Objectives Identify opportunities for physical therapy to integrate into
current emerging delivery and payment models. Describe approaches to payers and employers with the
business implications will be presented that influence these new models.
Understand challenges and potential solutions to successful implementation of a new program.
Identify key factors and metrics to understand if program is viable long term solution.
Gameplan What is PT First and what’s taking so long? What are payers and employers looking for from alternative
payment models? Key Implementation Strategies for Successful Training Monitoring, Feedback, and Clinical Reporting: What to do after
“Go Live” Analysis and Reporting for Business Intelligence
Why MSK? Why Now?
$865 BillionEstimated Value of the National MSK
Market
5.7% 20%Of Medical Expenditures
MSK Of GDP
May 1, 2023
MSK Overview – Patient Demand by Body Part
National MSK analysis via commercial claims data
75%Of all MSK cases are
Spine, Knee & Shoulder
% of MSK Touches
Therapy
Clinic Visits
Standard Imaging
Office Procedure
Advanced Imaging
ED/Urgent Visits
Specialist Pro-cedure
Home Health
50% Therapy
SG2 2012 Report
Does Therapy Matter?
What Health Systems See
Increasing pressure to improve while decreasing costs
Emerging value-based reimbursement1
2
75%
Chronic conditionsaccount for
of healthcare costs
In the U.S. and Growing
Medicare patients is readmitted within 30 days
1
Pressures on Health System
Most health systems are ill-prepared for this demand
Patients
Employers
Payers
Facing more lost time
More informed Payment Reform
Why Do Health Systems Care?
• Lower inpatient volume• Higher orthopedic costs but limited control• Physician dissatisfaction• Lower reimbursement rates• Uncertainty about how to manage episodic/bundled payments and
population health• Organizations that don't move fast enough in a changing landscape• Leakage of patients during the continuum of care• Market fragmentation
Full Service Health System Integrated Delivery System
Employed
Medical Staff
Faculty
Clinically Integrated
Employed Physicians and Outpatient Services
Payers
Post Acute Services
Diagnostic Center
ASC
Post Acute Services
Payers
Hospital System vs. Healthcare Delivery System
PT
What If?? (1) Identify appropriate
patient population… High volume
cases/admissions Variations in clinical
practices (2) Obtain commitment
from Leadership/Clinicians (3) Assemble
interdisciplinary team (4) Data review &
Benchmarking
(5) Evaluation of current practices
(6) Establish outcomes measures/indicators
(7) Sequential event mapping with outcomes triggers
(8) Staff & Patient education
(9) Implementation of pathway
PT First, A New Concept?
SpineAccess Alberta SpineAccess Alberta will
include multidisciplinary teams at two pilot centres who will assess, triage and treat patients with back problems.
At these pilot sites, these teams will help clear the health system of backlogs of patients waiting for unnecessary consultations and it will help the 10 percent who do need a specialist, see them faster.
http://www.albertahealthservices.ca/Strategic%20Clinical%20Networks/ahs-scn-bjh-spine-access.pdf
Imaging? New Zealand physiotherapists
are able to refer patients for x-ray and ultrasound (US) imaging.
Australia Wisconsin 2016…..
Littlejohn F, Nahna M, Newland C, Robins S, Hefford C (2006): What are the protocols and procedures for imaging referral by physiotherapists? New Zealand Journal of Physiotherapy 34(2): 81-87.
Unique Models (PT First)
Allow for innovation Must be Patient-Centered Demands Direct Access Must fit within the Scope of
Practice
http://forces4quality.org/node/6347
Scope of Practice Licensure is required in each state in which a physical therapist
practices and must be renewed on a regular basis, with a majority of states requiring continuing education as a requirement for renewal.
PTs must practice within the scope of physical therapy practice defined by these state licensure laws (physical therapy practice acts).
The entire practice act, including accompanying rules, constitutes the law governing physical therapy practice within a state.
http://www.apta.org/Licensure/StatePracticeActs/
What is “PT First”?3 Types of Direct Access Unrestricted: No referral language in the physical
therapy practice act.
Provision: No referral needed to access physical therapists examination, evaluation, and intervention with certain provisions.
Limited Direct Access: allows for access to evaluation and access for certain types of treatment.
Patient satisfaction and outcomes superior Decrease utilization of
numbers of PT visits, imaging ordered, medications prescribed, additional non-physical therapy appointments
There was no evidence for harm.
Phys Ther. 2014 Jan;94(1):14-30.
What is taking so long? Practice Act issues Placement in healthcare system
”Turf” wars Payer issues and awareness Employer awareness Clinical hurdles
Training insufficiencies Risk of rogue clinicians
Data Integration issues
Perspective
Executing “PT First” Payers Employers Unions Value-Based Arrangements
“PT First” and Payers Evidence-based approach provides value Tracking data is key Data has to tell a story that demonstrates savings, reduce
fragmented care & unnecessary care Pair with patient outcomes & satisfaction How the data is compiled and collected matters
Identify potential service models, patient populations, geographic overlap
Benefit design improves effectiveness, but not necessary Need well-defined implementation plan; need to drive the
process & keep it front & center IT integration improves results Ongoing communication is essential Collect data and make modifications as needed
“PT First” and Payers
Perspective
Revolutions
Genesis Identification of need Consultation with recognized specialists Proposed solution
Encouragement of PT as access point for musculoskeletal complaints
Evidence based medical screening Capitated shared risk payment model Standardized evidence informed treatment pathways
Genesis Proposed solution
Encouragement of PT as access point for musculoskeletal complaints
Evidence based medical screening Capitated shared risk payment model Standardized evidence informed treatment pathways
Implementation v1.0 (2012) Access: During first visit an onsite MD had to “bless” the
care plan Screening: As above with 10 item questionnaire Payment: $20 copayment regardless of deductible status Training: 8 hours training for neck and back management Scope: 12 clinics with 40 participating therapists
Lessons Learned in the First 6 Months
Patients did not mind coming via direct access (70% in first year) Patients did not like paying a physician copay when they added
no value Physicians did not like their busy clinic days disturbed by PT
coming to say they needed another patient “blessed” Programs change quickly when the HR department receives 18
phone calls in a month regarding erroneous copayments Too large of a rollout lead to inconsistencies in care and process
Lessons Learned in the First 6 Months
If you design a program for early acute access You’ll get a ton of patients with long term symptoms
But despite your reservations they get better
Reload v2.0 Encouragement of Direct Access No MD Blessing and 2nd copayment As described fee for service payment model with patient
copayment regardless of deductible status
Outcomes 45-60% reductions in disability High patient satisfaction Decreased health spend for hospital system (Imaging, Pharm) Decreased PTO Usage for those in program
Just Wasn't Sexy
2016 “SSK” Expansion
Stagnate growth of program Minimal hospital investment
Revitalization New found hospital support Opportunity to intergrade Knee and Shoulder patients Move to real time process and outcome monitoring Opportunity to refine screening process
Medical Screening Previous Criteria
Medical Screening Opportunity
• 2012-2014 ATI partnered with Greenville Health System (GHS) and BCBS SC to initiate clinical pathways
• GHS adult beneficiaries with back and neck pain eligible to seek initial care with 4 select co-located ATI clinics
BackBackNeck
GHS Musculoskeletal(MSK) Program
• 2016 ATI partnered with Greenville Health System (GHS) and BCBS SC to initiate clinical pathways
• GHS adult beneficiaries with spine, shoulder, & knee pain eligible to seek initial care with 9 select co-located ATI clinics
KneeSpine
(Neck/Back)Shoulder
GHS Musculoskeletal(MSK) Program
• Beginning Jan 1 2017• Expand program to include hip
• >50% of LBP has hip complaints
• 12% of non traumatic MSK visits
• Add 4 more ATI locations
Neck/BackHip/KneeShoulder
MSK ProgramFor Spine, Shoulder, Hip, and Knee Pain
PCPUrgent Care
Ortho Center
Refer back< 25% improvementNon MSK symptoms
Follow-ups@ 6 visits/30 daysIF> 25-50% better
Then…
Follow-ups another 30 days with
expectation of> 50% improvement 45
Ultimate Lessons Learned How do you eat a horse?
Changing health system behaviors is harder Ongoing process These things happen with one MD and one therapists deciding this
is how patients should be seen Turf protection and hubris is overcome with jealousy of their colleagues
Be like a duck Ferocious monitoring and course correction everyday Just as we planned when reporting out on great outcomes and huge
savings
KneeSpine
(Neck/Back)Shoulder
2016 “Report” Card
• 509 discharged from PT• Average age = 47.4 years• 79.5% are female
25% 31% 36% 6%
Body Region
MSKore • The majority of patients were in the 35-55 age range, with a predominance of women similar to GHS population.
• As for Body Mass Index, 56% of patients normal or less BMI.
Lumbar
ShoulderKnee
Cervical
34%
31%
15%
20%
Diagnostic Diversity: Percentage of total patients by body region
Female Male
403
106
Patient DemographicsCY16 Jan 1 – Dec 31
Mild
50
96%Patient satisfaction
Patient Outcomes CY16 Jan 1 – Dec 31
• 60% direct to PT• 85% without further
medical referral• 7.8 visits/patient
How am I doing?
Operational &Patient OutcomesBUT,
BUT, BUT…...
FEEDBACK TO CLINICS
Lutz et al Ortho Section Platforms Friday 12:45
Patient improvement < the predicted risk adjusted outcome
Patient improvement > the predicted risk adjusted outcome
You are here
FEEDBACK TO CLINICS
Lutz et al Ortho Section Platforms Friday 12:45
Patient improvement < the predicted risk adjusted outcome
Patient improvement > the predicted risk adjusted outcome
You are here
Annual Program Growth
54
25,000 covered lives/year
Annual Visit Comparison
55
25,000 covered lives/year
Populations were similar in terms of• Age• Gender• BMI• Comorbidities• Diagnostic
mix• Chronicity
Improved Access• ATI appointment within 48
hours Reduced cost• >26% reduction is total MSK
health spend• Avoidance of unnecessary treatments• 44% reduction in advanced
imaging • Increased patient satisfaction• 93% Patient Satisfaction Score
Improved outcome
•57% increase in patient functional outcomes
Decreased absenteeism• < 3.3 days/case sick time
Projected 3 year US Savings
15-33% savings across service lines
26% overall savings
Total US MSK Spend
$900 billion
$180 billionProjected Savings
Analysis and Reporting for Business Intelligence
Chris Stout, PhD, Vice President Research and Data Analytics
Well…
Why is working in healthcare so hard…?
It was nice to come to ATI work with workers’ comp outcomes because…
Outcomes are VERY Quantified– RTW at the same job description
and PDL or not?– How many days passed before
RTW?– Nice, clean, and tidy!
I was always frustrated with the disconnect of collecting
PROs in real-time for the clinician (as well as me!)
But we may have cracked the code
67
Passionate about Patient Satisfaction: Since its inception, ATI has been focused on our mission to provide the highest quality of care in a friendly and encouraging environment. We have the most inclusive, methodologically sound, and productive program in physical therapy. Last year alone, we sent out 222,354 patient satisfaction surveys and received 55,082 in return (a 25% response rate).• Each day, returned surveys are scanned into our IT infrastructure and are immediately
available to the Clinic Director and Operations Leadership. This allows the Clinic Director to share praises with the staff, as well as address anything that is not exceeding expectations related to quality of care or customer service. It is a concrete example of how the benefit of a strong IT platform enables ATI to maintain an extremely high-touch management environment where clinicians and managers can be immediately responsive to patient feedback.
• We are not content with small samples or biased data, so ATI invested in industry-leading methodology and was published in Advance for Physical Therapy for “What Patients Want: Innovative uses of patient satisfaction data in quality improvement and clinical management.”
68
ATI also introduced the use of the Net Promoter Score (NPS) to the physical therapy industry. The NPS is a customer loyalty metric used across many industries, including healthcare. It was introduced in Fred Reicheld’s 2003 Harvard Business Review article on the topic. Patients are asked, on a scale of 0-10, how likely they are to recommend ATI to friends and family. ATI outperforms many other well-known companies, which is a reflection of our commitment to delivering on our mission for every patient, every day.
Pioneering Patient Outcome Management in PT: ATI embedded a complete set of functional outcome tools directly into our EHR that are concise, easy to complete, reliable, valid, and universally recognized and respected by professionals in the field. They are immediately scored, have descriptive pop-up result information, and provide patient item responses. The findings are available to the clinician in real-time, and are aggregated for post-discharge analyses.
Leveraging quality clinical outcomes and member satisfaction scores, the Patient Outcomes Report establishes a baseline of the existing care continuum and its impact on patients’ quality of life. This customizable tool facilitates the creation and implementation of care plans that enhance clinical effectiveness, reduce the cost of care, and improve the patient experience.
MSKore is a proprietary tool developed by ATI to reference various descriptive analytical aspects of patient care specific to musculoskeletal (MSK) conditions
Enhancing Patient Clinical Outcomes While Favorably Influencing the Episodic Cost of Care for Musculoskeletal (MSK) Conditions
MSKore®
• 41% of the population in this examination was male, 59% female.• Most were between the ages of 50 to 59, with females exceeding males in this
age group. • The majority of patients fall into the normal category, followed by those
considered to be overweight.
Female Male
12,520
9,11642% of the population in this examination was male, 58% female.
Most were between the ages of 50 to 59, with females far exceeding males in this age group.
The majority of patients fall into the obese category, followed by those considered to be overweight.
3 %
32%
32%
33%
Patient Demographics
Referral Diversity: Percentage of total referrals by physician specialty
Physician SpecialtyOrthopedic
Family Practice
Internal Medicine
PodiatristPhysician Assistant
Neurosurgeon
Physical Medicine and Rehabilitation
56%12%
7%
2%
3%9%2%
Physician Demographics
The Majority of referrals came from Orthopedic Physicians Distant second was Family Practice and Internal Medicine
Physicians
15,000
5,000
0
10,000
Orthopedic Family Practice Internal Medicine
Physician AssistantPodiatrist
Neurosurgeon
Pediatric
Physical Medicine & RehabilitationOB/GYN
Health Care Education Nurse Practitioner
Other* Neurologist
All Referring Physician: The number of referrals by type
74
As XYZ-Comp may have regions in Illinois that would benefit from more outpatient treatment venues as well as improved rural outpatient coverage, this examination notes regions of Member density and potentials of partnership.Patient Distribution by
Clinic
ATI Investment in Market-Specific Outpatient Therapy
Physical Therapy at ATI
Body Part Total Number of Patients
Mean PT Duration Days
Average Number of Comorbids
Most frequently occurring comorbidity
Neck 987 xxx 2.6 ArthritisShoulder 1919 Xxx 2.2 ArthritisElbow/Wrist/Hand 765 Xxx 2.2 ArthritisLow back/Lumbar spine 2265 xxx 2.8 Arthritis
Hip 879 Xxx 2.6 ArthritisKnee 2309 Xxx 2.2 ArthritisFoot 1429 Xxx 1.8 Other Allergy
Totals 10553 xx.x 2.3 Arthritis
Payer
2016 Clinical Staff & Customer Service Clinic Facilities
RESP #Patient
Satisfaction
Clinical quality & treatment
Professional attitude, & appearance of all staff
Customer Service of all Staff
Billing and Payment process explanation
Were clearly defined goals set for your treatment?
Were your treatment goals achieved
Overall comfort & appeal of clinic
Location of clinic
XYZ 1696 92.94% 98.21% 99.45% 98.59% 89.87% 93.82% 95.44% 97.32% 99.37%ALL ATI 28877 93.68% 98.09% 99.10% 98.62% 93.12% 94.23% 94.50% 96.82% 99.30%
Quality and Patient Satisfaction
Registries-a-go-go
Not a problem of too little,
but too much
• 3600 statistical articles are published on average each year
• Do you know how long it would take you to keep up…?
Just for Coronary Heart Disease…
Anyone…?
If you read 1 article/15 minutes
You would have to read >10 articles
For 2.5 hours/day
7 days/week
Forever…
OK,So, now WHAT?
>15,000 prior-managed bills were loaded and rerun against the ODG Treatment UR
Advisor for each ICD9-CPT combination on frequency, number of visits,
recommendations from ODG Treatment, and the "Bill Review Payment (or ODG Approval)
Flags" divided into Green, Yellow, Red…
Green, OK to auto-pay up to ODG Codes for Automated Approval max number of visits;Yellow, OK to auto-pay up to 25th %tile number of visitsRed, need to review
Apple HealthKit
In 14 of 23 major hospitals are trialing (Google and Samsung discussing health-based technology plans)
Healthcare + fitness apps = comprehensive picture
Send to MD or case manager
Please be in [email protected] or visit DrChrisStout.com for these slides and references
