Only outcomes data will tell.
By Heidi Jannenga, PT, DPT, ATC/L
It is 2016—and we are living in a world where everyone wants to get more for less, even in health care. In fact, our entire country is in the midst of a massive health care reform effort, much of which is focused on delivering higher-quality care at a lower cost—which explains why so many of the recently created health care regulations, programs, and payment models reward value.
So, how does this impact physical therapists? We know our services are valuable, but unfortunately, that value is not widely understood or accepted among payers, patients, or other providers. It is our responsibility to change that—to make sure everyone knows how valuable physical therapists really are. This will ensure we do more than survive this new, value-based health care environment; we will thrive. First, we must actually prove the value of our services, ourselves, and our profession. And we must do so objectively—with outcomes data.
The Triple Aim
You may be wondering why tracking patient outcomes is so important all of a sudden. While it has always been an important aspect of evidence-based practice, the demand for this type of data collection has amplified in the last few months as a result of the Institute for Healthcare Improvement’s Triple Aim,¹ which is the driving force behind US health care reform. As the name suggests, the Triple Aim has three main objectives:
- Achieving better results (i.e., better patient outcomes)
- Decreasing the cost of care
- Increasing patient satisfaction
If you have been practicing for even a short while, you know how common it is for things in the policymaking world to move at a turtle’s pace. However, that is not the case here. In fact, the federal government is not wasting any time in its quest to reduce health care spending. To that end, in 2015, the US Department of Health and Human Services (HHS) announced it will:
- Base 30 percent of all Medicare fee-for-service (FFS) on alternative payment models by the end of 2016.²
- Increase that proportion to 50 percent by 2018.²
- Link 85 percent of FFS payments to outcome measures by the end of 2016.²
- Bump that percentage to 90 percent by the end of 2018.²
This rather aggressive timeline means that providers who do not jump on the outcomes-tracking train may end up feeling the pinch of an even more dire payment situation. Think about it: Medicare payment rates are already a common cause for complaint—and private payers tend to follow Medicare’s policy lead. So, in all likelihood, most—if not all—payments will be linked to value within the next few years.
So, what is outcomes tracking, anyway? In short, it is a way for health care providers to objectively measure patients’ functional progress and success via outcome measurement tools (OMTs). Typically, patients complete these at the onset of care, at the end of care, and at various points between. Of course, you, as the physical therapist, are able to see each patient’s progress, but the only way to draw meaningful conclusions about your patients’ progress overall—as well as your staff’s performance as a group—is to track those outcomes in an objective and scalable way. In other words, in order to demonstrate your value as a physical therapist, you need data—and outcomes tracking is the best, most logical method of obtaining that data.
Now, that being said, there is a big difference between merely recording numbers and generating meaningful, actionable insights, because when you do the latter, you can achieve three really important things:
1. Improve Patient Care
Outcomes data is unique, because it is tied to the efficacy of care. When providers can proactively collect and analyze this information themselves, they gain insight that they can use to improve care, streamline operations, identify best practices, and guide business decisions. The benefit of outcomes data does not stop at the individual provider level: When therapists create a large pool of collective data with the intent to improve patient care, the entire industry benefits, because we gain the ability to prove the effectiveness of physical therapy across the board. When we do that, payer networks will have more of an incentive to make physical therapy widely available and affordable to beneficiaries, which means patients will have better access to our cost-effective, noninvasive treatments.
2. Influence Payment Rates
In the past, many therapists shied away from collecting outcomes data because they were afraid it would negatively impact their contracts and, as a result, their finances; and that fear had some merit. Luckily, though, times are changing, because more of the data we are collecting today actually reflects the value we provide our patients. As an industry, we have the opportunity to demonstrate our ability to improve our patients’ lives and highlight the downstream cost savings we achieve. Once we collect enough data, we can leverage it to negotiate better payment rates, boost referrals, and even advocate for policies that ensure we are taken into consideration for future payment models. The more data points we gather, measure, and transform into meaningful, actionable information, the more influence we will have in creating the future we want.
3. Position Physical Therapists as Key Health Care Players
According to a research study cited by the American Physical Therapy Association (APTA),³ patients who seek therapy early in the course of treatment for low back pain generate significantly lower health care costs than patients who do not. And that is just one study. There are plenty of other musculoskeletal conditions for which this holds true. Unfortunately, it seems we might be the only ones who know this—because the general public does not. And with collaborative care models becoming the new norm, it is time we step in and claim our position as primary care practitioners—and command the recognition we deserve. To do so, we need concrete proof that definitively shows the results we are capable of achieving. In other words, we need outcomes data—and the right kind of outcomes data at that. This means we must:
- use standardized tools to collect outcomes data,
- select measurements recognized outside of the rehab therapy realm, and
- push to make our findings more widely available outside of individual clinics.
The Benefit to Your Practice
By now you know that outcomes data is an important piece of the proving-our-value puzzle—and that it impacts both care quality and payments. You also know that if physical therapists produce outcomes data on a large enough scale, it will help all of us better assert ourselves as neuromuscular experts. But those are longer plays. What about some immediate gratification? Well, as it turns out, outcomes data actually can help you be a better physical therapist and run a better practice—now. That is because you can use the data you collect to:
- Better assess clinical performance through benchmarking.
- Compare your clinic’s data to various data points for clinics in your region/specialty.
- Identify areas of need/competitive deficiencies and create correctional plans.
Sounds good, right? Now, on to the tactical stuff.
We are all clear on why outcomes data is beneficial and important, so let us talk about how to start tracking it. First of all, you can breathe a big sigh of relief, because you’re probably already completing outcomes tools and recording the information as part of your standard documentation, which is great. All that is left, then, is to establish the right processes and implement the right software—because to collect and analyze data in an accurate, timely, and consistent manner, you will need some type of software.
Of course, if you prefer to administer paper tests to your patients, you can still print them out, but it is best to record and store the results in a therapy-specific outcomes tracking software. I suggest doing so in a user-friendly, web-based system—preferably one that integrates with your electronic medical records (EMR). That way, you do not have to waste time—or risk any associated errors⁴—with double data entry. Plus, the system will instantly record the data you collect within the appropriate medical record. This type of software makes it much easier to hold yourself and your staff members accountable for consistently collecting outcomes information. This last step is important, because with any data-tracking endeavor, consistency is key.
Additionally, the right software contains a hand-picked library of evidence-based, industry-accepted tests that are already familiar to—and respected within—the health care community at large (e.g., QuickDASH, LEFS, Oswestry, Neck Disability Index, and Dizziness Handicap Inventory). You also want those tests to be risk adjusted for complicating factors such as age, weight, litigation, diabetes, cancer, and heart diseases, so you can easily and accurately compare different types of patients.
Now, collecting meaningful data will take a little bit of extra work, but think of it less as a burden and more as an opportunity—one that will soon be the norm. Like any worthwhile endeavor, the end result is worth it. Physical therapists have a huge opportunity here to shine in this pay-for-performance era—and to take the driver’s seat for a change. If we execute on this correctly, we will have the power to save our patients money, improve our clinics’ bottom lines, and solidly position ourselves as primary care providers. Now that is a win-win-win.
1. The IHI Triple Aim. Available at www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx. Accessed February 12, 2016.
2. Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. HHS.gov (2015). Available at www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Accessed February 12, 2016.
3. Early Guideline-Based Physical Therapy Results in Health Care Savings for Patients with LBP. Early Guideline-Based Physical Therapy Results in Health Care Savings for Patients With LBP (2015). Available at www.apta.org/ptinmotion/news/2015/4/9/adherentptlbp. Accessed February 12, 2016.
4. Goldberg SI, Niemierko A, Turchin A. Analysis of Data Errors in Clinical Research Databases. AMIA Annual Symposium Proceedings (2008). Available at www.ncbi.nlm.nih.gov/pmc/articles/pmc2656002. Accessed February 12, 2016.
Heidi Jannenga, PT, DPT, ATC/L, is the founder and president of WebPT. She can be reached at firstname.lastname@example.org.
Reflections from past winners of the Private Practice Section’s Student Business Concept Contest
By Dr. Chris Wilson, PT, DPT, CHES
Another great Private Practice Section Annual Conference has come and gone. Last year, I was lucky enough to attend as the 2014 winner of the Student Business Concept Contest. This year I took part as a Private Practice Section member as well as an owner. Serving on the Membership Development Committee, I had the privilege of meeting and interacting with this year’s winners first hand (as well as the fast moving newly-formed SSIG leadership). I was reminded of how much impact the Student Business Concept Contest had on me and thought it was a great time to reach out to other past winners and see if they had similar experiences.
First, let’s talk a little background. Every year since 2006, PPS has sponsored the contest with up to two students winning an all-expenses paid trip to the PPS Annual Conference. Destinations have previously included the Broadmoor in Colorado Springs as well as other resort-type destinations in New Orleans and Orlando. The financial value of the conference is estimated at $2,000 but the real value to the innovative students (who are selected based on their unique and complete business concept proposal) is found in the experiences they have.
In 2008, Travis Orth won. At the time, it was a much different contest—less about a business concept and more an essay contest about the future of private practice physical therapy. While Travis is still working toward a goal of opening a multidisciplinary clinic with superior patient care, he notes specific benefits of winning the contest. In particular, meeting the PPS president at the time, Steven Anderson. Anderson is the president of Therapeutic Associates. Thanks to their connection, Travis landed his first job and had numerous other offers based on connections he made at PPS Annual Conference. His advice to current students: “Talk to as many people as possible, just take in the whole experience!”
In 2009, Jeff Donatelle also won the essay contest by describing his aspirations to be a private practice owner. Jeff was smart to solicit the advice and editing skills of a mentor at the private practice in which he was finishing a clinical rotation. He notes that attending the annual conference as the student winner exposed him to innovators and forward thinkers who dominate the private practice section. It galvanized his resolve to work in a private practice physical therapy setting as well as instilling in him a unique understanding in the value of the PT PAC for which he has lead successful fundraising campaigns. He notes that it was a great experience and actively encourages today’s students to submit nominations.
In 2010, Mike Giunta was the first winner of the Student Business Concept Contest in its current format. His unique model revolved around incorporating community events such as food and clothing drives with wellness and fitness initiatives. Mike was also one of the first to bridge his idea into a real product that his clinic sponsors regularly. Like Jeff, he notes a primary benefit of winning the contest was the value derived in a unique networking opportunity. And, like Jeff, he also secured his first job outside of physical therapy school through connections made at Annual Conference. However, one unique value proposition he notes is that simply taking the effort to apply is a great exercise in thinking outside the box. He notes that developing a mindset of young professionals who think outside the box is critical to the future of the profession.
In 2012, Justin Lee was selected as one of the winners for his concept RevoPT. It was a unique way to create custom home exercise programs with smartphone technologies. Justin and his partner Michael Wehrhahn were further along than most in winning the concept having won some other awards and investors along the way. They approached the Annual Conference as an opportunity to sell their product and, in hindsight, view that as a mistake. Like the other winners, Justin noted the real value is likely the connections made and he was unable to make as many connections because of his focus on selling his product. However, he did gain a better appreciation for the business mindset and business considerations of private practice owners as a result of his participation. His big takeaway: You need to understand your value proposition and be able to articulate it in a way that is meaningful to your target audience.
In summary, there are a great deal of benefits from both submitting and winning the contest. In addition to an all-expenses paid trip to fantastic destinations, you are also developing an outside the box mentality, establishing a unique network of mentors, gaining a unique understanding of the business side of PT and possibly securing a great position after you graduate. Applications are due July 2015, so start developing your concept now and submit at http://www.ppsapta.org/c/StudentContest.cfm.
By Marisa Munoz-Parada, Practice Administrator
Efficient operations form the solid foundation on which successful practices are built. Implementing operational change can often create fear, anxiety, and resistance among clinicians and staff. This uneasiness further affects the practice’s ability to “team build” and create and maintain a healthy practice culture. Although team building and operational change appear to be in opposition, they can be successfully integrated and achieved with care from both the office administrator and the clinic’s owners.
When I began my tenure as office administrator in 2012, I had the opportunity to experience this challenge firsthand, implementing needed operational change while maintaining, improving, and refining our healthy culture of team building. I quickly realized that many “best practice” protocols were in place. Front office procedures, business development programs, and clinical practice metrics were efficient—developed by lessons learned since the clinic opened in 2008. In spite of these protocols, a lack of efficient EMR and billing software use, weak clinician billing practices, documentation, and follow-up on cancellations needed attention or in some cases, complete overhaul.
We began by establishing the culture of absolute teamwork and purpose. Christoph Lueneburger, a Harvard Business Review contributor and sustainability expert, states: “When a company communicates its purpose [a pledge to do the right thing] and demonstrates a strong commitment to it, the company becomes a force for good and creator of value for all stakeholders, especially employees.”1 We achieved this goal with frequent and effective communication and operational changes reflective of our mission—fine-tuning, polishing, and building our teamwork “mojo” one operational change at a time.
We demonstrated the importance of every job function to employees by educating all staff on how lack of purpose on one employee’s part could negatively affect all others. This often became humorous when front office staff shared their daily work experiences with clinicians, although it brought to light the need for care and purpose with our individual actions.
As expected, this took time as well as patience, but the information provided to the owners, clinicians, and staff relieved the fear of change and fostered the team building culture that we were striving to achieve. In a sense, we became more vulnerable but were able to work together and move forward with the solutions.
Although I can cite many examples, one stands out: accountability and follow-through on the part of each staff member. In the past, many changes were implemented only to fail because of inconsistent follow-through by the staff and poor accountability monitoring by the administration. Staff grew to expect it. Accountability and team building waned and the operational change fell away. Looking back, this was not only a disservice to our practice but also to the employees who were receiving mixed messages about our culture and what our expectations were of them.
We corrected this by returning to several processes that had fallen victim to complacency and reintroduced them with a new fervor to appropriate staff. As the administrator, I (along with the owners) made sure all questions and issues that arose were addressed immediately to ensure success. Staff members became more engaged and proud of their accomplishments and those who were at the top of their game were rewarded with small incentives such as gift cards and recognition throughout the practice. We all had a purpose and were each an important link in the chain. All in all we have made tremendous progress.
1. Christoph Lueneburger, Harvard Business Review, website /hbr.org/2014/12/a-companys-good-deeds-can-energize-employees. Published December 3, 2014. Accessed April 2015.
Marisa Munoz-Parada is practice administrator for Rozina and Smith Physical Therapy in Upland, California. She can be reached at email@example.com.
By Stacy M. Menz, PT, DPT, PCS
As business owners, we are always faced with decisions that need to be made. Do we sign an insurance contract, do we hire another staff member, do we expand locations, do we institute a 401k plan, do we take on a business partner—the list is endless. So how do we make the “best” decision, if that even exists?
Any decisions made will affect those in and around your practice differently. Who are these interested parties? This could mean you as the business owner, your employees, your clients, your referral sources, your vendors, your business partners . . . again, a long list. How do you approach decisions, and at the heart of those decisions, what do you use as your guides? What are your absolutes? Do you decide to make the decision that has the potential for the least harm to all interested parties, but does not really allow for what you want or need, or do you make a different decision that supports your goals but could have a less than desirable effect on others involved?
These questions are endless and if you do not have a clear idea of what your practice stands for, these questions have the potential to paralyze you. Identify what your practice’s values are . . . not the things you aspire to be but what you, your team, and your clients see when they look around your practice. Whatever those things are, hold tight to them and do not waver. These things define you and will guide you when the decisions get hard.
My favorite example of this is a story related in Patrick Lencioni’s book, The Big 3 Questions for a Frantic Family (Jossey-Bass, October 2008). When he talks about values, he uses the example of Southwest Airlines. One of the core values Southwest embodies is humor. It is woven into everything they do. As such, a long-time customer was on a plane and the cabin steward was going over the safety instructions using a great deal of humor. The customer was upset by this and felt it was an inappropriate topic to joke about so went on to write a letter to the chief executive officer (CEO) of the airlines. As the story goes, the CEO promptly replied with a short letter stating, “We will miss you.” The CEO stood by that core value of humor even if it meant losing a long-time customer because he understood what was at the core of the company and team . . . and what their success was built on.
If you have not already, take some time to define what these values are for your practice and then guard them fiercely in all of your decisions and planning.
By Terry C. Brown, PT, DPT
There is little that affects a private practitioner’s ability to deliver effective quality care more than payment. It remains the number one concern of our members and their ability to thrive. The payment environment we practice in puts all the discussion and concern regarding the America Physical Therapy Association’s (APTA) payment reform initiatives into context. Discussions on this topic are all over the place—from hopeful optimism to apocalyptic demise. Not surprising, as this is the lifeblood of our practices and the income for not only our families but also all who we employ.
The questions surrounding this effort far outweigh the answers. What will the new Current Procedural Terminology (CPT) codes look like? What will payment for new codes be? Will it be adequate for us to thrive? How do we plan for future growth of our practices? Will there be new administrative burdens attached to this effort? Is what we have now better than what we might be given? If we manage our practice as we always have, will it limit our future in private practice?
Perhaps we should start with what we do know:
- The present system of fee for service is a nightmare of manipulation and counting minutes in order to receive a constantly shrinking, barely sustainable fee.
- The administrative burdens continue to bog down therapists and limit our patient care time.
- The current system completely ignores any successful efforts to provide quality and cost effective services.
Is this system working for you? Is it promoting your cost-effective quality service?
Is this system working for you? Is it promoting your cost-effective quality service?
Provider and payer alike are recognizing this system as broken. Reform is inevitable; it is happening all around us, in all of aspects of health care beyond physical therapy. The National Commission on Physician Payment Reform has called for a phasing out of fee-for-service within the next five years. Their article in the New England Journal of Medicine1 reports a blueprint for a new physician’s fee schedule that recommends fee for service payment be eliminated because of its inherent inefficiencies and problematic financial incentives. It also recommends transition to an approach based on quality and value. Health and Human Services (HHS) recently outlined their goals as they strive to move to a value-based payment system, with efforts being apparent as soon as 2016.2
APTA has been proactively working on a new model of payment for physical therapists and has recently gained approval for new evaluation codes based on patients’ presentation and the work of the provider. Ongoing work is being done on treatment codes over the next several months. Much effort has gone into these new coding structures to support the developing payment models. Much work still needs to be done.
My fellow Private Practice Section (PPS) members, change is coming with or without our participation. Innovation of payment methodology and related reporting mechanisms are needed. This will require the knowledge of business leaders in our section working with APTA to be innovative in effecting real change, change that will benefit physical therapists that provide quality care with real outcomes. PPS members need to take the challenge to become engaged and direct change so that we are not negatively impacted by its outcome.
1. New England Journal of Medicine www.nejm.org/doi/full/10.1056/NEJMsb1302322. Accessed May 2015.
2. Health and Human Services www.hhs.gov/news/press/2015pres/03/20150325b.html