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  • 2014-09-September

Video Analysis

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Using contemporary technology to improve clinical assessment.

By Brian Hoke, PT, DPT, SCS, CGFI Andrew Altman, PT, MPT, ATC David Volkringer, PT, MPT, and Katie Johnson, PT, DPT
What is the common element in the following events: a soccer player lands a jump, a pitcher throws a ball, a long distance runner makes contact with the ground, and a golfer makes impact with the ball on the tee? They all take place in less than one second, and the movement that occurs cannot be accurately assessed with the unaided eye. The integration of video technology solves this clinical dilemma by capturing the motion and allowing the clinician to replay the motion at a much slower rate to analyze posture, joint positions, and symmetry. Video technology has evolved greatly from the days of the first tape-based systems. Some will recall the VHS and Sony Beta technology of yesteryear, with its large recording units and cameras. The cost of the equipment was high and slow motion playback was often “fuzzy” with poor definition. Fast forward to modern technology for video capture and playback, and the user is provided with several video options that are more compact, affordable, and produce a much higher definition playback for slow motion clinical analysis. In our physical therapy practice, we use video capture
  • to analyze landing patterns that reveal a higher risk of anterior cruciate ligament (ACL) injuries
  • to analyze the throwing motion in baseball
  • to analyze the swing path and body positions during the golf swing
  • to analyze gait patterns for walking and running

ACL Injury Risk Evaluation

In the United States alone, there are more than 200,000 ACL injuries annually. Of these, approximately 65 percent will undergo reconstructive surgery. This has consequentially created an increase in the numbers of rehabilitative cases seen in the physical therapy outpatient setting. As a result, there has been much attention toward designing a physical therapy training program that will not only result in predictably good outcomes, but also one that is able to test and predict the level of injury and or re-injury.

There have been many efforts toward determining various risk factors that lead to ACL injuries, and high valgus moments, especially with anterior tibial forces, have been determined to result in strain and increase the risk of rupture of the ACL1,2,3,4. A Drop Jump Test objectively measures the athlete’s ability to control lower limb axial alignment in the frontal plane.

To perform the video analysis, the patient jumps off a box on to the ground and then immediately jumps in to a maximum vertical jump. The camera captures the jump in four specific phases; just as the toes are touching the ground (pre-landing), the landing (deepest position), the take-off in to the maximum jump, and the maximum jump.

The knee valgus angle can also be measured to objectively document the higher risk athlete who demonstrates greater valgus angle on landing.

Clinically, we have found that the video analysis of the drop jump test is a standardized, time-efficient measurement tool that can be performed easily in a physical therapy office.

Biomechanical Throwing Analysis

High-speed video analysis can be a valuable tool to assess a baseball player’s faulty mechanics as they perform the movement of throwing. A portable system is necessary to video at a baseball field, which can be analyzed and reviewed at your physical therapy practice with the player, coach, and parents. To perform a good quality video analysis for a baseball pitcher:
  1. The player should wear clothing that affords good exposure of the throwing arm, trunk, and legs. Have the player shirtless or in tight clothing so that all land marks and joints can be identified. Sliding shorts or bike shorts are useful to video the lower trunk and hips.
  2. Mark necessary landmarks with small retroreflective markers such as ScotchLite® Adhesive Tape. You can also use a permanent felt-tip marker.
  3. Film three to five pitches from three different views: second base view (behind pitcher), home plate view (front view), and open side (left handed pitcher would be from first base and a right handed pitcher would be from third base.)

During analysis, identify the biomechanical faults observed in the thrower’s motion to decrease the athlete’s risk of injury and/or improve a thrower’s performance and development of maximal pitch velocity. After reviewing your analysis with the athlete and other key individuals, such as parents, coaches, and sports agents, it is not uncommon for them to recommend the analysis to other players and coaches.

Gait Analysis for Walking and Running

During walking the foot is only on the ground for six tenths of a second, and when we run stance phase is as short as 2/10 of a second.

Integrating video into the evaluative process enables the clinician to observe the gait pattern in a frame-by-frame manner and find the exact moment in gait where the subject reaches maximal pronation. At this point we are able to use an angle tool to compare the difference between the left and right subtalar joints. As a result of the analysis, the plan of care may include strengthening for the lower limb decelerators, a footwear recommendation, or orthotic therapy. A marked difference between the left and right sides may also lead the clinician to look further up the kinetic chain to determine if there is a reason behind the difference, such as a limb length discrepancy, pelvic asymmetry, or scoliosis.

Vertical displacement of the center of mass is another predictor of running efficiency. Decreasing vertical displacement improves performance by using less energy to go up and down and spend more we have for moving forward. We use the video software to find the lowest and highest points during the subject’s gait cycle and use the calibrated line segment tool to determine the distance that the runner travelled up and down.

Video capture and playback software enables the clinician to slow down movements that are too fast for the naked eye to see and educate the athlete regarding their biomechanical faults or movement inefficiencies and identify excessive or inadequate motion that can be altered to improve performance or reduce the potential for injury.

Golf Swing Analysis

Down-The-Line Golf Swing Video Capture

Down-The-Line Golf Swing Video Capture

Face-On Golf Swing Video Capture

Face-On Golf Swing Video Capture

Video analysis of golfers’ swings is a common practice by teaching golf professionals and on sports coverage of televised professional golf events. For the clinician, a brief analysis of a golfer’s swing can assist in detecting faults that can increase the risk of injury and also impair a golfer’s performance.

The video analysis of a golfer’s swing is typically done from two views: “face on” and “down the line.” The “face-on” view (Figure A) is done by filming facing the player as they swing. This provides useful information regarding proper weight transfer during the swing as well as lateral sway of the hips and pelvis during the swing. The second view is “down the line” (Figure B) filmed by standing behind the player facing their target. This view is extremely helpful in analyzing the golfer’s posture, swing plane, and rotation of the hip and pelvis.

What You Need to Get Started

Knee extension of trail leg leading to Reverse Pivot swing fault

Knee extension of trail leg leading to Reverse Pivot swing fault

Takeaway and swing path

Takeaway and swing path

To begin video analysis, you will need a camcorder, preferably with the ability to record in high definition, a tripod to keep the camera steady while filming, and a computer with a memory card reader or USB cable to connect the camera to load the video for analysis. For the analysis itself, you may choose from many user-friendly software packages. Some of the more commonly used programs available for purchase are Dartfish, Sports Motion Analysis, and Coach’s Eye. There are also very useful public domain programs for the clinician, such as V1 Home and Kinovea.

Capturing and printing the video frames that reveal the most useful information can be helpful and providing video images to the patient is a marketing opportunity. People love to see themselves on the video since it is a perspective that they cannot otherwise obtain, and they will often share this information with other athletes and coaches. When the patient has been referred by a physician or coach for the video analysis, make sure the referral source also gets a copy of the video images, as well as a concise summary of the significant findings.

Summary

The integration of video analysis into clinical practice can open the door to more accurate analysis of functional movements, particularly in the high velocity movements of common sports. The information obtained can assist the clinician in identifying factors that increase the risk of injury, cause the body to move into abnormal patterns of compensation, and impair optimal sports performance. From this information, corrective measures can be developed, and subsequent analysis can further assess the effectiveness of treatment interventions. In addition to providing an extremely valuable clinical tool for the clinician, this novel service can also be a new source of revenue for the clinical practice. This is particularly true in the absence of injury, where the goal is injury risk reduction and improved performance. If people in your community value this service, it can provide significant cash-based revenues.

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The following are examples of four common swing faults that can be demonstrated on the video and linked to specific problems that can be addressed by a physical therapist:

Reverse Pivot: If a golfer allows the trail leg to move into knee extension during the backswing (Figure C) and subsequently fails to make proper weight transfer to their lead foot in the downswing, they will hit “off their back foot.” This can often be corrected with core stabilization of the lower trunk musculature, lower extremity postural stabilization exercises in a flexed knee position, and better proprioceptive awareness and balance ability.

Improper Swing Path: If the golfer swings the club outside the ideal swing path on the backswing, they will repeat the path on the downswing imparting a left to right sidespin to the subsequent ball flight (“slicing”). When this is observed in the video analysis, it may reflect a lack of thoracic rotation or inadequate shoulder external rotation range of the trailing shoulder.

Loss of Golf Posture: In an ideal golf swing, the golfer maintains a consistent spine angle from takeaway to impact with the ball. This creates consistency in bringing the club head back to a “square” position as the club is brought through the impact zone. When the loss of golf posture occurs, the golfer fails to maintain a stable spine angle (Figure B) during the swing, becoming more upright during the golf swing. This can be related to inadequate strength and stability in the hip and pelvis and can frequently be corrected with core stabilization exercises for the gluteals and lower abdominal musculature.

Shortened Swing Arc: A golfer’s swing arc is related to the power developed and ultimately the distance that the ball travels. When the golfer fails to bring the club back fully in the backswing there is a loss of power and distance. The video analysis provides an easy tool to observe the length of the arc of a golfer’s swing (Figure D). Tightness in the posterior shoulder of the lead arm, loss of hip internal rotation of the trail leg, and limitation of trunk rotation can all lead to a shorter backswing.

 

Brian Hoke, PT, DPT, SCS, CGFI, is a PPS member, co-owner of Atlantic Physical Therapy, PC, in Virginia Beach, VA, and a Titleist Certified GolfFitness Instructor. He can be reached at hokeptscs@aol.com.

Andrew Altman, PT, MPT, ATC, is co-owner of Atlantic Physical Therapy, PC. He can be reached at aatlmanpt@aol.com.

David Volkringer, PT, MPT, OCS, is a physical therapist with Atlantic Physical Therapy, PC. He can be reached at dvolkringer@gmail.com.

Katie Johnson, PT, DPT, is a physical therapist with Atlantic Physical Therapy, PC, and a former Division 1 soccer athlete. She can be reached at katieannj@gmail.com.

 

Notes

1. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics 2000; 23: 573-8.

2. Boden BP, Torg JS, Knowles SB, Hewett TE. Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009;37(2):252-259.

3. Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003;35(10):1745-1750.

4. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am. J. Sports Med. 2005; 33: 492-501.

5. Zebis MK, Andersen LL, Bencke J, et al. Identification of athletes at future risk of anterior cruciate ligament ruptures by neuromuscular screening. Am. J. Sports Med. 2009; 37: 1967-73.

A Medley of Compliance Questions

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By Mary R. Daulong, PT, CHC, CHP

Q: Does Medicare require all outpatient therapists, billing Part B, to be enrolled in Medicare and to have a Medicare Provider Transaction Access Number (PTAN)?

A: Yes, I believe that Medicare mandates that a physical therapist be enrolled in the Federal Program when billing Part B Medicare. The rationale for my “yes” is based on the following regulations:

Therapist refers only to a qualified physical therapist, occupational therapist, or speech-language pathologist. TPP refers to therapists in private practice (qualified physical therapists, occupational therapists, and speech-language pathologists).

To qualify to bill Medicare directly as a therapist, each individual must be enrolled as a private practitioner and employed in one of the following practice types: an unincorporated solo practice, unincorporated partnership, unincorporated group practice, physician/NPP group or groups that are not professional corporations if allowed by state and local law. Physician/NPP group practices may employ TPP if state and local law permits this employee relationship.1

For purposes of this provision, a physician/NPP group, practice is defined as one or more physicians/NPPs enrolled with Medicare who may bill as one entity. For further details on issues concerning enrollment, see the provider enrollment Website at www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program Integrity Manual, chapter15, section 15.4.4.9.

This CMS Program Integrity Manual specifies the resources and procedures Medicare fee-for-service contractors must use to establish and maintain provider and supplier enrollment in the Medicare program. These procedures apply to carriers, fiscal intermediaries, Medicare administrative contractors, and the National Supplier Clearinghouse (NSC), unless contract specifications state otherwise.

No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider and supplier enroll with the appropriate Medicare fee-for-service contractor.2

Q: Is it true that Medicare is using a Fraud Prevention System (FPS) to identify aberrant billing by providers and suppliers? If so, how do I know what they consider aberrant?

A: Yes, Medicare introduced this system about three years ago, and it has been very successful. The system allows Medicare to identify atypical or aberrant billing behavior. This predictive analytic technology is used to identify the highest risk claims for fraud, waste, and abuse in real time; and it stopped, prevented, or identified $115 million in payments, resulting in an estimated $3 for every $1 spent in its very first year.

A few examples of aberrant billing that would could be identified by the FPS for therapists are:

  • Redundant coding (e.g., using the same code sets for each date of service and/or for all patients regardless of their diagnosis)
  • Excessive use of the therapy cap exceptions (exceeding the peer average with no evidence of co-morbidities or complexities to justify the coding behavior)
  • Billing up to the therapy cap and never attesting to a therapy cap exception need
  • Abnormally high units of service under one National Provider Idenitifier (NPI)
  • Abnormally high billing with Advanced Beneficiary Notices (ABNs) noting “not medically necessary or statutorily non-covered services”
  • Disregard of Local Coverage Determination requirements and/or restrictions

Q: I know one of the seven recommended elements of a Compliance Program is monitoring and auditing. What should I be monitoring and auditing?

A: You are very prudent to be concerned about the “monitoring and auditing” element of a Compliance Program as this is how you prove its effectiveness. Compliance Programs are dynamic and require regular monitoring to determine if a policy, procedure, or process is current and reflects present day regulations. Many practitioners use a question process which, while revealing, can be less than comprehensive. Questions such as:

  • Is there a risk of internal fraud or theft?
  • Is there a risk of a protected health information (PHI) breach?
  • Is there a risk of hiring a person who is excluded from providing services to federal beneficiaries?
  • Is there a risk of exposing an employee to Bloodborne Pathogens?
  • Is there a risk of filling inaccurate or fraudulent claims?
  • Is there a risk of non-compliance with federal and/or state supervisory requirements?
  • Is there a risk of a patient abandonment claim?
  • Is there a risk of patient and/or staff harm due to a fire in the facility?

A risk assessment is a more thorough method to monitor effectiveness. The risk assessment is often divided into regulatory categories so it can be managed in separate time frames. These categories, typically, have many subsections which identify specific requirements or risk areas associated with the regulations; the detail of this method assists in the monitoring or auditing process. An example of some regulatory categories would be:

  • Fraud & Abuse
  • Office of the Inspector General List of Excluded Individuals & Entities
  • Payor Regulations
  • Human Resources/Labor Law

Health Insurance Portability and Accountability Act (HIPAA)/Health Information Technology for Economic and Clinical Health Act (HITECH)

  • Occupational Safety and Health Administration
  • Americans with Disabilities Act
  • State Practice Act
  • Town, City & Municipality Ordinances

In addition, I recommend using a compliance calendar to provide guidance regarding the timing of required activities mandated by payers, agencies, and other regulators. The use of a compliance tracking system is, also very helpful in verifying the status of functions completed, as well as corrective action plans.

Q: What is the difference between a HIPAA security incident and a HIPAA security breach?

A: HIPAA security standards define a “security incident” as an attempted or successful access, use, disclosure, modification, or destruction of information on a system without appropriate authorization. The incident need not involve “protected health information” to qualify as a security incident, as many security incidents occur because they compromise the security of the system and are attempts to bypass security controls.

Some examples of security incidents that would be germane and/or of potential risk are:

  • Shared passwords
  • Unlocked screens and/or extended log-off times
  • Worm, virus, and/or malware infections
  • Access and/or attempts to access applications or the Internet without authorization
  • Social browsing (employees/students without E-PHI access rights)
  • Unauthorized software downloads (e.g., screen savers)
  • Saving data to the local drive verses the server
  • Unprotected laptops used in or in transit to remote sites

On the other hand, a “security breach” is any impermissible use or disclosure of PHI that is presumed to be a breach, with a subsequent requirement to provide a breach notification, unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised. Importantly, the covered entity or business associate, as applicable, has the burden of demonstrating that all notifications were provided or that an impermissible use or disclosure did not constitute a breach, and they must maintain documentation sufficient to meet that burden of proof.

In determining whether notice of a breach is required, a covered entity or business associate must consider at least the following factors:

  • The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification
  • The unauthorized person who used the PHI or to whom the disclosure was made
  • Whether the PHI was actually acquired or viewed
  • The extent to which the risk to the PHI has been mitigated

Q: What audits that should be performed to comply with HIPAA/HITECH/Affordable Care Act Security Regulations?

A: Some of the typical security audits that you should conduct to be proactive are:

  • Network or Local Drive Audits (e.g., patches and ports)
  • Baseline Security Analyzer Audits (e.g., Security Update Status)
  • Back Up Logs or Reports (verify reproducibility)
  • Electronic Medical Records Access Audits
  • Practice Management Program Access Audits
  • Web Access Audits
  • Company and Personal Device Password Compliance
  • Remote User Security Measures (e.g., firewalls, antivirus software).
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Mary R. Daulong, PT , CHC, CHP, is a PPS member and the owner of Business & Clinical Management Services, Inc., a consulting firm specializing in outpatient therapy compliance, including documentation, coding and billing, enrollment and credentialing, and Health Insurance Portability and Accountability Act and Occupational Safety and Health Administration regulation education. She is also the author of both The Private Practice Compliance Manual and The Third-Party Biller Compliance Manual. She can be reached at daulongm@earthlink.net.

 

 

Notes

1. CMS Benefits Policy Manual, Chapter 15 Section 230.4, Services Furnished by a Therapist in Private Practice (TPP),(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14).

2. CMS Program Integrity Manual, Chapter 15 Section 15.1, Introduction to Provider Enrollment, (Rev. 347, Issued: 07-15-10, Effective: 07-30-10, Implementation: 07-30-10).

The Peak of Change

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Navigating through the ceaseless changes in health care.

By John Sievers, MPH, MHA

This spring, I vacationed with my family in Mesa, Arizona, where we took advantage of the numerous hiking trails winding through Superstition Mountains. Our most story-worthy adventure involved a trail that leads to the top of Flat Iron Mountain and boasts a varied difficulty rating between “moderate” and “intense.” Getting to the top required that we leave behind a clearly marked trail—because it ended halfway up the mountain—and navigate the rest of our journey by trial, error, and instinct. More than once my family and I had to back-track and pursue another path, but the reward was well worth the effort; the view of Phoenix from atop Flat Iron Mountain and the sense of accomplishment that came from making the journey was truly unbeatable.

This experience is not unlike navigating the ceaseless changes in health care, specifically as they relate to the many business models for physical therapy service delivery. There are stretches of time when it seems like we are on a clearly marked trail, headed in a sure direction—then without warning the trail disappears, and we are left to find our own way to the top.

As frustrating as this may seem, we have only just begun the climb. Physical therapy delivery models face a wealth of change in the near future, including payment methodology, physician alignments, development of provider networks, and the consolidation of health care systems.

The general agreement is that the health care industry’s current state is not sustainable, and while most recognize that the next five years will look nothing like the last five, how to position and pursue the best course of action is still not a clearly marked path. With the specific details and timing of change unknown, physical therapy owners are hesitant to craft a clearly defined strategy. They recognize that they are facing huge decisions for the future of their company, but are reluctant to act amidst so many fluctuating variables.

Looking ahead, three industry trends are likely to take root in the coming months, which will affect the future environment for nearly all physical therapy centers.

Changing Trends in Health Care

  1. Payment will decline. Medicare and commercial payors face increased rate regulation, tougher medical loss ratio requirements, and the establishment of health insurance exchanges, which increases transparency and forces premiums downward. Given these pressures across the major payor classes, payments to facilities will suffer.
  2. Alternatives to fee-for-service payment will become more prevalent. Commercial payors, Medicare, and state agencies will continue to refine alternative payment concepts that transition from fee-for-service towards pay-for-performance, episode-based bundled payments, and population-based reimbursement.
  3. Increased availability of provider-specific information on the price for a specific health care service. As health care costs continue to rise, purchasers will focus on strategies that can bring costs under control. These pressures have facilitated a movement by many purchasers to engage consumers more fully in their health care decisions, including taking on a greater share of their health care costs. In their efforts to manage costs, health care purchasers—including large employers—recognize consumers need information on both health care price and quality.

As these trends evolve and begin to affect practice owners, the most critical change may be the degree and pace of transition from volume-based payment schemes to value-based alternatives.

Even facing this change, many facilities will choose to stay the course and hope for the best, especially in markets where net payment is favorable and owners are still enjoying strong profit margins. Regardless, the options you elect to implement or reject will go a long way in determining the future sustainability of your company. As you consider what route to take for yourself and your facility, keep in mind the market variables, which change as frequently as the market itself.

MARKET VARIABLES

Payment Rates in Your Market
  • Analysis of net revenue per visit both current and trending
  • Evaluate payor mix and individual contractual fee schedules
Current Profit Margins
  • Review of year-over-year patterns and future forecasting
  • Determine potential to reduce expenses—both fixed and variable
Consolidation among Physicians & Health Systems
  • How will organizational restructuring of referral sources affect your facilities?
  • Assess potential impact of Accountable Care Organizations (ACOs) and bundle payment arrangements
Ability to Capture Market Share
  • Your ability to maintain and grow same store volume
  • Effect of high deductible insurance plans and Health Savings Accounts (HSAs)

Fortunately, despite the changes and the variables within them, you have many options to position yourself and your physical therapy facility to gain a competitive advantage. While every possibility needs to be weighed against your long-term personal and business objectives, I recommend that independent physical therapy facilities consider expansion and growth strategies, mergers and acquisitions, integrated network alignment, or succession planning.

BUSINESS MODEL DELIVERY OPTIONS

Expansion & Growth Strategies
  • Focus on increased case volume and payment
  • Determine cost/benefit of offering new service lines
  • Offer carve-outs with self-insured and commercial insurers
Mergers & Acquisitions
  • Target local/regional market competitors
  • Potential to create greater value for future monetizing transaction
  • Leverage economies of scale with respect to billing, software, and human relations.
Integrated Network Alignment
  • Evaluate various options available in your market
  • Determine competitive advantages that local networks could offer
  • Assess Professional Services Arrangements (PSAs) with health systems
Succession Planning
  • Determine best course of action to monetize ownership
  • Target current employees for potential succession strategy
  • Develop 2 to 3 year plan of action to transition

The bottom line is to prepare for everything. You cannot know when your paved trail will end, you cannot determine which obstacles will cross your path or when, and you cannot always know the variables you will have to address when considering how to position (or reposition) your facility. Take time to review market trends and studies and align your practice with a group that has in-depth understanding of what is going to affect health care change and how it will wind its way to you.

The journey ahead will transition facilities to compete and there will be difficult stages along the trail. But it is still possible to reach the top. There is always an alternate route—find one that makes it possible for you to keep pressing forward.

John Sievers, MPH, MHA, is vice president of Physical Therapy Business Development at Nueterra. He can be reached at jsievers@nueterra.com.

Patient or Customer?

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By Tannus Quatre, PT, MBA

Health care has roots in tradition and authority. Medical providers—experts in the human condition—have long been put on pedestals by those they serve out of respect and reverence for their knowledge. While there is nothing fundamentally wrong with a relationship built on respect and admiration, some believe that the inherent imbalance of power between the provider and patient has perverted basic market influences such as customer choice, price transparency, and competition.

As consumers bear increasing financial responsibility for their care, a shift is occurring in which consumers are becoming more discriminating with regard to choice of provider. This shift is coming as a shock to many providers entrenched in the health care paradigm of yesterday.

Acknowledging this shift and responding to it with an approach to a market that views consumers not as patients (old paradigm) but rather as customers (new paradigm) will allow providers to continue to evolve our profession in a way that serves new demands as they come our way.

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Tannus Quatre, PT, MBA, ATC, CSCS, lives at the intersection of physical therapy and entrepreneurship, spending his time helping physical therapists build and operate successful practices through his company, Vantage Clinical Solutions. He specializes in marketing, finance, and business planning, and authors and speaks regularly for the APTA and PPS. He can be reached at tannus@vantageclinicalsolutions.com.

Mark A. Anderson, PT

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Mark A. Anderson, PT, is president and founder of Mountain Land Rehabilitation in Salt Lake City, Utah. He can be reached at mark@mlrehab.com.

Mountain Land Rehabilitation includes Mountain Land Physical Therapy, Brighton Rehabilitation, Western Rehabilitation Health Network, and Mountain Land Rehabilitation Home Health with 32 outpatient clinic locations, six hospital contracts, 49 skilled nursing facility contracts, two home health agencies and 60 home health contracts, and 950 full- and part-time employees. The practice was founded 29 years ago.

Most influential person who enhanced your professional career and why: The most influential person in my professional career was my grandfather. Growing up next door to him, I spent considerable time with him as he ran his small business. He taught me not to be afraid of taking risks and to work hard. He also taught me the “Golden Rule—to always consider what is best for others as you do business with them.”

Describe the flow of your average day and when or if you still treat patients, perform management tasks, answer emails, and market: My career path has led me out of clinical practice and into various management roles within our organization. As president, my primary role is to develop and implement the organization’s strategies. I am involved in business development, market forecasting, and business relations. I am involved in state and federal government affairs, with focus on health care regulation and legislation.

Describe your essential business philosophy: Promote our vision and core values throughout the organization. I place great value on my partners, our employees, and our patients. Everything we do should assist all stakeholders to achieve their greatest potential.

What have been your best, worst, and toughest decisions? Hiring the right people for the team is the most important decision we make. Finding exceptional people who share our values and are passionate about our profession is paramount in achieving success.

How did you get your start in private practice? In 1984, I opened an outpatient practice in Park City, Utah. I practiced out of an old house with the waiting room in the front room and hydrotherapy in the kitchen. It was a lot of fun.

How do you stay ahead of the competition? I strongly believe in an abundance mentality. Over the years, I have gone to great lengths to work with and collaborate with our competition. From forming therapy networks to establishing study groups, I have never regretted building rapport. I was taught many years ago by my first physical therapist employer that having an exceptional therapist open up an office down the street is actually a positive, not a negative. High quality, ethical competition is good for everyone.

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What are the benefits of PPS membership to your practice? I have been going to PPS conferences for as long as I have been practicing. I owe much of my understanding of the business side of physical therapy to my peers in the PPS. I always come away from PPS fall conference with many new pearls of wisdom. I also have gained countless friends and resources within the membership of PPS.

What is your life motto? Make work fun, and it is no longer work. One of our core values is “have fun.” I believe I am the champion of this core value.

What worries you about the future of private practice/what you are optimistic about? I am concerned that payors may lose perspective of the value and worth of physical therapy. Unscrupulous business practices and referral for profit scenarios tarnish our reputation. I am optimistic for the growing need for physical therapy care for an aging population. We are the cost-effective alternative to promote independence and function within this population.

What new opportunities do you plan to pursue in the next year? We are building expertise in several niche areas. We believe that diversifying from third-party paid services is an important element of our future success. We also are on a quest for standardizing our outcome and electronic medical record data collection to better prepare for case rate reimbursement and affordable care organization collaboration opportunities. 

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